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nE MONIING SYSTEM CERTIFI ION GEIVEL) For Use By All Jurisdictions Within the State of California OCT 13 2015 Authority Cited.-Chapter 67, 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. if more thaii ti '' .a A separate certification or report must be prepared for each monitoring system control panel by the technicianuA cc) hl L 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 Bldg.No.: Site Address: 1137 W LATHROP City: MANTECA CA Zip: 95354 Facility Contact Person: RICK Contact Phone No.: (209) 824-2760 Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 8/1912015 B. Inventory of Equipment Tested/Certified Check t c a2propriate boxes to indicates ecitic a ui ment inspected/serviced:: i Tank ID: 87 Tank ID: 91 ®In-Tank Gauging Probe. Model: VEEDER ROOT N In-Tank Gauging Probe. Model: VEEDER ROOT N Annular Space or Vault Sensor. Model: 420NACUUM N Annular Space or Vault Sensor. Model: 420/VACUUM ®Piping Sump/Trench Sensor(s). Model: 208/304 ®Piping Sump/Trench Sensor(s). Model: 2081304 N Fill Sump Sensor(s). Model: 208/304 N Fill Sump Sensor(s). Model: 2081304 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: N Electronic Line Leak Detector. Model: PLLD ®Electronic Line Leak Detector. Model: PLLD N Tank Overfill/High-Level Sensor. Model: VEEDER ROOT ALARM N Tank Overfill/High-Level Sensor. Model: VEEDER ROOT ALARM ❑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 ID: DIESEL Tank ID: _ N In-Tank Gauging Probe. Model: VEEDER ROOT ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 4201VACUUM ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s), Model: 208/304 ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensor(s). Model: 208/304 ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector, Model: PLLD ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: VEEDER ROOT ALARM ❑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). Dispenser ID: 112 Dispenser ID: 314 N Dispenser Containment Sensor(s). Model: 2081304 ®Dispenser Containment Sensor(s). Model: 2081304 N Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 516 Dispenser ID: 718 N Dispenser Containment Sensor(s). Model: 2081304 ®Dispenser Containment Sensor(s). Model: 208/304 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11112 N Dispenser Containment Sensor(s). Model: 208/304 ®Dispenser Containment Sensor(s). Model: 2081304 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser 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-I 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 ® Alarm h' report Technician Name(print): GARY HARRIS Signature: Certification No.: 8340501 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: 8/19/2015 Uhf-036—1/6 wrvw.unidocs.org Rev.01/17/08