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MONITORING SYSTEM. CERTACATION f'or Use By At/Juriselictions Within the State of California Authority Cited.• Chapter 6.7, Health arrcl Scfet),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 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 Service Bldg.No.: Site Address: 2615 W.Grant Line Blvd. City: Tracy Zip: 95304 Facility Contact Person: Hakimi Contact Phone No.: (925) 339-0039 Make/Model of Monitoring System: TLS-350 — Date of Testing/Servicing: 3-1-2017 B. Inventory of Equipment Tested/Certified Check thea ro riale boxes to indicatespecific equipment inspected/serviced:. Tan It ID: T1 -91 Split 10K Tank ID: T2 -DSL Split 5K ®In-Tank Gauging Probe. Model: VR-MAG 90-107 ®In=Tank Gauging Probe. Model: VR-MAG 90-107 ®Annular Space or Vault Sensor. Model: VR 303 L-4 Annular Space or Vault Sensor. Model: VR 303 L-4 ®Piping Sump/Trench Sensor(s). Model: VR 208 L-5 ®Piping Sump/'French Sensor(s). Model: VR 208 L-7 I ID Fill Sump Sensor(s). Model: VR 208 L-6 ®Fill Sump Sensor(s). Model: VR 208 L-8 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: Veeder Root ®Electronic Line Leak Detector. Model: Veeder Root ID Tank Overfill/High-Level Sensor. Model: OVERFILL ®'rank Overfill/I ligh-Level Sensor. Model: OVERFILL ❑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: T3-87 20K Tank ID: ®In-rank Gauging Probe. Model: VR-MAG 90-107 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: VR 303 L-1 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: VR 208 L-2 ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensor(s). Model: VR 208 L-3 ❑Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: Veeder Root ❑Electronic Line Leak Detector. Model: ®Tank Overfill/Fligh-Level Sensor. Model: OVERFILL ❑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: 3/4 ®Dispenser Containment Sensor(s). Model: VR 208 L-14 ®Dispenser Containment Sensor(s). Model: VR 208 L-15 ®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: 7/8 ®Dispenser Containment Sensor(s). Model: VR 208 L-13 ®Dispenser Containment Scnsor(s). Model: VR 208 L-12 ®Slicer Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9110 Dispenser ID: 11/12 ®Dispenser Containment Sensor(s). Model: VR 208 L-10 ®Dispenser Containment Sensor(s). Model: VR 208 L-11 ED Slicer Valve(s), ®Slicer 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 Platt showing the layout of monitoring eq ut ment. For any equi meat capable of generating such reports,I have also attached a copy of the report;(check all dial apply): 9 System set-up Alarm history report Technician Name(print): Robert S. Carr Signature: kd_ C.oLJZ/�� Certification No.: 8340716 License.No.: 1014934 Testing Company Natne: Valley Petri leum 8r Lift Inc. Phone No.:(559) 271-3300 "Testing Company Address: 3755 W. G--ttysburg Ave., Fresno, CA 93722 Datc of Tcsting/Sorvicing: 3-1-2017 Page 1 of 3 Rev(2/08)