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RECE" ' w JUL 06 ad p �L$ MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California hitIInOVn IFNTAL Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16,Division 3, Title 23, Californ' de of Aq u This form must be used to document testing and servicing of monitoring equipment. 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: West Valley Auto Care Chevron Bldg.No.: Site Address: 2515W.Grant Line Rd City: Tracy Zip: 95304 Facility Contact Person: Site Manager Contact Phone No.: (209) Make/Model of Monitoring System: Veeder Root TLS350 Date of Testing/Servicing: 6/28/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins pected/wrN iced: Tank ID: T-1 Supreme 91 Tank ID: T-2 Diesel Z In-Tank Gauging Probe. Model: 847390-107 ®In-Tank Gauging Probe. Model: 847390-107 Z Annular Space or Vault Sensor. Model: 794390-303 split tank ®Annular Space or Vault Sensor. Model: 794390-303 split tank Z Piping Sump/Trench Sensor(s). Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 794380-208 ®Fill Sump Sensor(s). Model: 794380-208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: PLLD Z Electronic Line Leak Detector. Model: PLLD Z Tank Overfill/High-Level Sensor. Model: Horn/Light Z Tank Overfill/High-Level Sensor. Model: Horn/Light ❑0(her(specify equipment type and model in Section E on Page'). ❑Other(specify equipment type and model in Section E on Page'_). Tank ID: T-3 Regular Tank ID: Z In-Tank Gauging Probe. Model: 847390-107 ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794390-303 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 794380-208 ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: PLLD ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model: Norn/Light ❑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: 1-2 Dispenser Ill: 3-4 Z Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containnicia I and Chain(s). ❑Dispenser Containmen(Float(s)and('hain(S). Dispenser ID: 5-6 Dispenser ID: 7-8 ®Dispenser Containment Sensor(s). Model: 79480-208 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(,)and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z 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 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 Z Alarm history report Technician Name(print): Aneil Chand Signature: l' - Certification No.: A21873 License.No.: ICC 5119959 Testing Company Name: Pinnacle Fuel Compliance Services, Inc. Phone No.:(408) 206-9840 Testing Company Address: P.O. Box 32849 San Jose,CA 95152-2849 Date of Testing/Servicing: 6/28/2017 Page 1 of 3