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T RECEIVED MAR i 6 2018 -L O,HYLIA MGE WlTX....IUENGE. MONITORING SYSTEM CERTIFICATION Fmwlnr,nin,;'7AL For Use By All Jurisdictions Within the State of California -,-.)ff =NIT 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 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 West Grant Road o City: Tracy Zip: 95304 Facility Contact Person: Rick Branchinl Contact Phone No.: 925-699-1396 Make/Model of Monitoring System: Veeder-Root TLS-350 Date of Testing/Servicing:03/05/2018 B. Inventory of Equipment Tested/Certified Check theappropriate boxes to indicatespecific aqui mart inspected/serviced: Tank ID: 87 20,000 gal. Tank ID: 91 9500 gal. In-Tank Gauging Probe. Model: 847390-107 / In-Tank Gauging Probe. Model: 847390-107 v Annular Space or Vault Sensor. Model: 794380-303 / Annular Space or Vault Sensor. Model: 794380.303 Piping Sump/Trench Sensor(s). Model: 794380.208 / Piping Sump/Trench Sensor(s). Model: 794380-208 v Fill Sump Sensor(s). Model: 794380-208 / Fill Sump Sensor(s). Model: 794380-208 Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: a Electronic Line Leak Detector. Model: uwLLD / Electronic Line Leak Detector. Model: wPLLD Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other(specify equipment t e and model in Section E on Page 2). Other(specify equipment t e and model in Section E on Page 2). Tank ID: Diesel 4600 qal. Tank ID: In-Tank Gauging Probe. Model: 847390-107 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794380-303 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 794380-208 Piping Sump/Trench Sensor(s). Model: t Fill Sump Sensor(s). Model: 794380-20e Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: wPLLD Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other JsEecify equipment t e and model in Section E on Page 2). Other(specify equipment t e and model in Section E on Pae 2). Dispenser ID: 1-2 Dispenser ID: 3-4 v Dispenser Containment Sensor(s). Model: 794380-208 / Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). is Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 5.6 Dispenser ID: 7-8 -7 Dispenser Containment Sensor(s). Model: 794380-208 ✓ Dispenser Containment Sensor(s). Model: 794380-208 0 Shear Valve(s). 7 Shear Valve(s). ❑ Dispenser Containment Floats and Chains. Dispenser Containment Floats and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 Z Dispenser Containment Sensor(s). Model: 794380-208 Dispenser Containment Sensor(s). Model: 794380-208 V1 Shear Valve(s). Shear Valve(s). 11Dispenser Containment Floats and Chains ❑ Dispenser Containment Floats 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): 2 System set-up 7 Alarm history report [�// Technician Name(print):Kyle Self Signature: X�o' Veeder Root No.: TLS-350 License.No.:804904 Testing Company Name: Confidence UST Services Phone No.:661-631-3870 Testing Company Address: 16250 Meacham Road,Bakersfield,CA 93314 Date of Testing/Servicing: 03/05/2018 Monitoring System Certification Page 1 of 4 12/07 1 2/21/07