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MONITORING SYSTEM CERTIFICATION 1--or Use By All Jurisdictions Within the State of California Authority Cited:-Chapter 6-7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations ,—,This form must be used to document testing and servicing of monitoring equipment.dik<d a+. tth faeitibr a A separate certification or report must be prepared for each monitoring 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 form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Cruisers Manteca BP29 _ Bldg.No.: Site Address: 1137 W Lathrop _ City: Manteca Zip: 95336 Facility Contact Person: Contact Phone No.: (209) 824-2760 Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Seryicing. 812212017 B. Inventory of Equipment Tested/Certified ' Check the agprogriate boxes to indicatespecific equipment ins ected1scrvicedi; 'rank ID: Diesel Tank ID SPR ❑In-Tank Gauging Probe. Model: ❑In=Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 3Q4 ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model; ❑Piping Sump i Trench Scnsor(s). Model: ®Fill Surnp Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Modcl: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line leak Dclector. Model. ❑Electronic Line Leak Detector. Model: ❑Electronic't,ine I eak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank 1D. Tank ID: ❑In-Tan;Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s) Model ❑Piping Sump/Trench Sensor(s). Modcl: ❑Fill Sump Sensor(s). Model: ❑Fili Sump Sensor(s) Model ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic line 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 Section E on Page 2). ❑Other(specify equipment type and model in Section L on Page 21. r Dispenser ID: Dispenser 10: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s) Model: ❑Shear Valve(s). ❑Shear Valvc(s). ❑Disperser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Scnsor(s) Model: ❑Dispenser Containment Sensor(O. Model: ❑Shear Valve(s). [],Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser 1D: z Dispenser ID: ❑Dispenser Containment Senser(s). Model ❑Dispenser Containment Sensor(s)- Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). [jDispenser Containment Float(s)and Chain(s) 'If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility C. Certification -1 certify that the equipment identified in this document was inspected/serviced 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,I have also attached a copy of the report;(check all that applv); ®System set-up Technician Name(print): Mark Steinhauer Signature: Certification No.: B47431 _ License. No.: Testing Company Name: L.C.SERVICES _ _ Phone No.:(559) 444-1730 Testing Company Address: 3887 N VALENTINE FRESNO CA 93722 Date of Testing/Servicing: 8/22/2017 UN-036- 1/6 Asyw.unidocs.org Rev.01/17/08