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0 0 RECEIVED 13 Monitoring System Equipment Certiflcatbn 2017 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, Califor ALT RMENT This form must be used to document testing and servicing of monitoring equipment. A separate certificion or rrenorrt mus atbe 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 system within 30 days of test date. A. General Information Facility Name:Unocal Bldg.No.: Site Address: 2701 West March Lane City: Stockton, CA Zip: 95219 Facility Contact Person: darren Contact Phone No.: (209)473-7337 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 12/15/16 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank I%01-Rego Tank ID: 02-Prem ® In-Tank Gauging Probe. Model: VR 847390-10e ® In-Tank Gauging Probe. Model: VR 847390-109 8 Annular Space or Vault Sensor. Model: VR 794390.420 ® Annular Space or Vault Sensor. Model: VR 794390.420 IN Piping Sump\Trench Sensor(s). Model: VR 794390-208 ® Piping Sump\Trench Sensor(s). Model: VR 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: Vaporless LD2000 0 Mechanical Line Leak Detector. Model: Vaporless L02000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill\High-Level Sensor. Model: VR 790081-001 gl Tank Overfill\High-Level Sensor. Model: VR 790091-001 ❑ 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:03-Diesel Tank ID• ® In-Tank Gauging Probe. Model: VR 848400.001 ❑ In-Tank Gauging Probe. Model: is Annular Space or Vault Sensor. Model: VR 794390.420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump\Trench Sensor(s). Model: VR 794380-208 ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: RJ 118.058.8 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill\High-Level Sensor. Model: VR 790091-001 ❑ 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: 01-02 03-04 p EDispenser ID: ❑ Dispenser Containment Sensor(s). Model: Containment Sensor(s). Model: ® Shear Valve(s). ve(s). Dispenser Containment Float(s)and Chain(s). Containment Float(s)and Chain(s). Dispenser ID: 05-0`3 Dispenser II}- 07-08 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ol Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). 11-12 Dispenser ID! 09-10 . p Dispenser ID. ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). 01 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 manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'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; (cbeckall that apply): 11 System set-up ® Alarm history report Technician Name(print): Randy Wilkerson Signature: LILL-_ Mfg.Cert.#.: A32404 ICC# 5258560-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 95112 Date of Testing/Servicing: 12/15/16