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MONITORING SYSTEM CERTIFICATION h-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. �a+e t �r+c-tr+itfx+rag�ystcetrrrErcpasrel i�instal a tile Jae:J+4y.a 1 separate certificsstion or report must be prcnared 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. '['he owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. - ,3 A. General Information Facility Name: Cruisers Manteca BP29 Bldg.No.: -m.61=NT 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/Servicing: 8/22/2017 B. Inventory of Equipment Tested/Certified Check the aecrocriate boxes to indicate specific equipment inspected/serviced:; 'rank ID: Diesel Tank ID: ❑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/Trench Scrrsor(s). Model: ®Fill Sump Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: _ I ❑Mechanical Line Irak Detector. Model: ❑Mechanical Line Leak Detector Model. ❑Electronic Line Leak Detector. Model ❑Electronic Line leak Dctcctor. 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--I ank Gauging Probe. Model: ❑In-'rank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Senser(s) Model ❑Piping Sump I Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model. ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Mudel. ❑Tank Overfill I High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). Other equipment type and model in Seaiat Lori Page 2). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensors) Model: ❑Shear Valve(s). ❑Shear Valvc(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floal(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s) Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valvc(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID.- [I D:❑Dispenser Containment Senser(s). Model ❑Dispenser Containment Sensor(s). Model: ❑Shear V81Ve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s) i *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at lite 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 apply): ®System set-up Technician Name(print): Mark Steinhauer Signature: ✓ ____ Certification No.: 1347431 ___ 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 w ww.unidocs.org Rev.01/17/08