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MONI'TORIA JMVP RUIFICATION I For UseBy All Jurisdictions Within the State of California I Authority Cited.--Chapter 6.7, lfeolth and Safery Code; Chapter 16,Division 3, Title 23, Cal/fortlla Code of Reguladoru � , ,jbis form must be used to document testing and servicing of monitoring equipment. Ffmc�tc tis u+. n itering ey�tan+cvntr<rl-f+a�+o!is�n ,Iled a+ tl+e faeiNta A sevaralo cetiiCcatlon or�cnort must be rp enarc�jor each monitotittg system control panel by the technician who performs the work, A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this Corm to the local agency regulating UST systems within 30 days of test date.—ins(roctieeralwprittt + pap-, I I A. General Information FacilityNarne: Cruisers Manteca 13P29 Bldg.No.: Site.Address: _1137 W Lathrop _ _ ' _ City: Manteca Zip: 85336 is Facility Contact Person: Contact Phone No.: (209) 824-2760 Make/Model of Monitoring System: VEEDER ROOT TLS-360 Date of Testing/Servicing; 812212017 B. Inventory of Equipment Tested/Certified Check Wt sggrotrisle hoxts to indicate s eciGe telaitpnitrit Inspected/serviced 1 Tank ID: Diesel Tank ID: ❑In-Tank(}auging Probe. Model: ❑in-Tank Gauging Probe. Model: *Annular Space or Vault Sensor. Model: 304 ❑Annular Space or Vault Sensor. Model: Iit ❑Piping Sump/Trench Sensor(s). Model; ❑Piping Sump/Trench Setssor(s). Model: ®Pill Sump Sensor(s). Model: 299 ❑rill Sump Sensor(s). Model: ❑Mechanical Line Leak Deteclor. Model- ❑Mechanical Line Unk Dcteclor. Modcl: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak t)oeaor. Model: ❑Tank Ovcrfitl/High-Level Sensor. Model: ❑Tank Overfill/High-level Scmot. Model: 1 Other(specify equipment type and model in Section H on Page 2). ❑Other(specify equipment type and model in Section E on Page 2), ; i TI k IV: Tank ID: n-Tank Gauging Probe. Model: ❑In•Tank Gauging Probe. Model: annular Space or Vault Sensor. Madel: ❑Annutar Space or Will Sensor. Model: ❑Piping Sump i Trench Sensor(s). Model: ❑Piping Sump I Trench Scrtsorts). Model: ❑fill Sump scnsor(s). Modcl: E]Piq Sump Sensor(s). Model: ❑Mechanical Line U4 Detector. Model: ❑Mechanical Linc Leak Detector. Model: Ne ❑ ctronic Linc Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ©Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Stenon E on Page 2). ❑011ier(specify equipment type and model in Section E on Page 2). i i Dispenser ID: Dispenser ID: i ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Seosor(s). Model: ❑Shear Valve(s). ❑Shear Vaivc(s). ❑Dispenser Containment Floa(s)and Chafn(s). ❑Dispenser Containment Picat(s)and Chain(s). i Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors) Model: ❑Dispenser Containment Sensor(s). Model: ❑&hear Vaive(s). ❑Shear Valve(s). ❑Dispenser Containment Floa(s)and Chain(s). ❑Dispenser Containmem Fioat(s)and Chain(s). Dispenser 1D: Dispenser ID: s ❑Disparscr Containment Scnsor(s). Model: ❑Dispenser Containment Scnsor(s). Model: it ❑Shear velve(s). El Shear Valvc(s). I ❑Dispenser Containment Float(s)and Chain(s)- ❑Dispenser Containment Float(s)and Chain(s). 1f the facility contains more tanks or dispensers,copy this form. Include Information for every tank and dispenser,at the facility. i C. Certification-I certify that the equipment identified in this document was inspectedlservictd in accordance with the manufacturers' gulddine3. Attached to this Certification Is information (e.g, manufacturers' checklists) necessary to verify that this information is 3 correct and a Site-hloLI'lan showing the layout of monitoriug equipment. For any equi ntent capable of generating such reports,I have I i also attached a copy of the report;(check all that apply); ®System set-up f Technician Name(print): Mark Steinhauer Signature: Carl l6cation No.: 847431 - License. No.: ` Testing Company Name: L.C.SERVICES _ Phone No.:(559) 444-1730 Testing Company Address: 3687 N VALENTINE FRESNO CA 93722 Date of Testilloervicing: 812212017__ I UN-036-116 w+swmnidocs.org Rev.01/17/08 i