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-= cL MONITORING SYSTEM CERTIFICATION For 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 separate certification or report must be orepared 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: 2515 W.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 thea rru printe buses to indicatespecific equipment ins rected/seniced: 'rank ID: T-1 Supreme 91 Tank ID: T-2 Diesel ®In-Tank Gauging Probe. Motel: 847390-107 ®In-Tank Gauging Probe. Model: 847390-107 ®Annular Space or Vault Sensor. Model: 794390-303 split tank ®Annular Space or Vault Sensor. Model: 794390-303 split tank ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Fill Sump Sensor(s). Model: 794380-208 ®Fill Sump Scnsor(s). Model: 794380-208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Linc Leak Detector. Model: ®Electronic Line Leak Detector. Model: PLLD ®Electronic Line Leak Detector. Model: PLLD ®Tank Overfill/High-Level Sensor. Model: Horn I Light ®Tank Overfill t High-Level Sensor. Model: Horn/Light ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). 'rank ID: T-3 Regular rank ID: ®In-Tank Gauging Probe. Model: 847390-107 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Madel: 794390-303 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Piping Sump/Trench Sensot(s). Model: ®Fill Sump Sensor(s). Model: 794380-208 ❑Fill Sump SenvAs). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: PLLD ❑Electronic Line Leak Detector. Madel: ®Tank Overfill/High-Level Sensor. Madel: Norn/Light ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section F on Page?1. ❑Other(specify equipment type and model in Section F on Page 2). Dispenser ID: 1-2 Dispenser 1D: 3-4 i ®Dispenser Containment Seruor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). NI, lel 794380-208 ®Shear Valve(s). ®Shear Valve(s). ❑DispenserContaill ment Pl)atlI)and Ch:Ill la, ❑DispenserContainmcnt Floatul and Chain(;(. Dispenser ID: 5-6 Dispenser ID: 7-8 E Dispenser Containment Sensor(s). Model: 79480-208 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment I loat(s)and Chain(s). ❑Dispenser Containment Floaus)and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 — -- ®Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Af the facility contains more tanks or dispenscrS,cohy this I'mm. 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 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 history,report Technician Name(print): Aneil Chand Signature:-- f� 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