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MONITORING SYSTEM CERTIFICATION For Use lar.911 Jurisdictinr)s Wilhin the State of Culijorniu 'Authority Cited- C'hupter 6.7. Health and SgPoly('ode, Chapter 16, Division 3. Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. l #ateWill ePAW01 PAHA _' HINI011 the #a A separate certification or report must be prepared for each monitoring system control gancl b% the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The ownerioperator must submit a copy of this Torn to the local agent% regulating UST systems within 30 days of test date. 011 1he bdel,01 4W,rtige: CEIVED to A. General Information APR �$ Facility Name: CRUISERS MANTECA BP29 Bldg.No.: Site Address: 1137 W LATHROP _ City: MANTECA, CA EN NNIENIAl Facility Contact Person: MONICA _ Contact Phone No.: (20W-Wfig^A,RTh4ENT Make/Model of Monitoring System: VEERD ROOT TLS-350 Date of Testing/Servicing: 8/25/2016 13. In enton of Equipment Tested/Certified (heck the appropriate hoves to indicates cific a ui tient ins mrR•d wrs ir•rd, Tank ID:_87 Tank ID: 91 ®In-tank Gauging Probc. Model VEEDER ROOT ®In-Tank Gauging Prohe. Model: VEEDER ROOT ®Annular Space or Vault Sensor. Model 304 ®Annular Space or Vault Sensor. Model 304 ®Piping Sump/Trench Sensur(s). Model 208 ®Piping Sump/'I Tench Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model 208 ®Fill Sump Sensnnsl Model 208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model ®Electronic Line Leak Detector. Model: VEEDER ROOT ®Flectronic Line Leak Detector. Model: VEEDER ROOT ®bank Overfill/High-Level Sensor. Model: OVERFILL ®lank Overfill/High-Level Sensor. Model: OVERFILL ❑Other(specify equipment type and model in Scown I nn Parc 2) ❑Other(specifi equipment type and model in Section I on Paec 2) Tank ID: DIESEL Tank ID: ®In-1 ank Gauging Probe. Model: VEEDER ROOT ❑In-I ank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 304 ❑Annular Space or Vault Sensor. Model Piping Sump/Trench Sensor(s). Model: 208 ❑Piping Sump/Trench Sensor(s). Model ®Fill Sump Sensor(s). Model: 208 ❑Pill Sump Sensor(s). Model: ❑Mechanical Linc leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak I)ctector. Model: VEEDER ROOT ❑1 Icaronic Line Leak Detector. Model: ®Tank Overfill/I ligh-Level Sensor. Model: FLAPPER ❑ Tank Overfill/Iligh-Level Sensor. Model: ❑Other(specify equipment type and model in Section I on Page 2) ❑oilier(specify equipment type and model in Section E on Page 21 Dispenser ID: 112 Dispenser ID: 314 I h,penser((mtainment Sensor(s). Model: 208 ® Di,penserC'onlamment Sensor(s). Model: 206 ®Shear Valvcu). ®Shcar Valve(s). ❑Dispenser((,mainnleut I+Nil s)and Chaim sl ❑I),prn,cr Containment I-lont(s)and Chain(s). Dispenser ID: 516 Dispenser ID: 718 ®Dispenser Containment Sensor(s). Model: 208 ®DispenserContanmrot Sensorts). Model: 208 ®Shear Valve(s). ®Shear Valve(s). f ❑Dispenser Containment I loat(s)and Chauusl ❑DispenserContuunn,cnt I loap,)and Chain(s). Dispenser ID: 9110 1 Dispenser ID: 11112 ®Dispenser Containment Scrrsorfs) Model: 208 ®DispenserContamment ticnsor(s) Model: 208 ®Shear Valves) ®Shear Valve(s). ❑Dispcn.ur(unrainmcm I I at(,)and C'hain(%) ❑Dispenser Containment Float(s)and Chain(s). *Ifthe facility contains more tanks or dispensers.copy this form. Include infisrmation for even tank and dispenser at the facility C. Certification - I certifN that the equipment identified in this document was ins pectedlserviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists► necessary to verify that this information is correct and a Site Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports.1 have also attached a copy of the report; (check all that app!),): ❑ S}stem set-up ❑ Alarm history r port Technician Name(print): GABRIEL VENEGAS Signature:_ �5 �� 1. �, ✓ Certification No.: B40893 I icensc_..No.: Testing Company Name: L.C.SERVICES Phone No.:(559) 444-1730 Testing Company Address: 3887 N VALENTINE FRESNO CA 93722 Date of Test ing'Sery icing: 8/25/2016 LAN-1136—1/6 Ne A.unidocs.org Rev.01/17/08