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Monitoring System Equipment Certification For Use By Alf 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 segaWc ggr1ifizati2n or rsp2rt must he nreogred-fol each monitoring stem g2mrolnal)el 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 March Ln. City: Stockton, CA — Zip: 95219 Facility Contact Person: Manager Contact Phone No.: (209) 473-7337 Make/Model of Monitoring System- V/R TLS -360 Date of Testing/Servicing: 12/18/13 B. Inventory of Equipment Tested/Certified rherk the 2nnmnr1sit& haipt to indieAte sn"ifir entainment insnerted/serviced! Tank IQ; 01-Regu Tank IQ: 02 -Prom M In - Tank Gauging Probe. Model: Vit"73MM M In - Tank Gauging Probe. Model: VR $47389I09 M Annular Space or Vault Sensor. Model: VR 79430420 0 Annular Space or Vault Sensor. Model: VR 7MO420 M Piping Sump \ Trench Sensor (s). Model: VR 794399208 M Piping Sump \ Trench Sensor (s), Model: - VR 794380-208 0 Fill Sump Sensor (s). Model: [I Fill Sump Sensor (s). Model: M Mechanical Line Leak Detector. Model: vaporless LD2000 M Mechanical Line Leak Detector. Model: Vae!ftss LD2000 [3 Electronic Line Leak Detector. Model: [3 Electronic Line Leak Detector. Model: C) Tank Overfill \ High -Level Sensor. Model: —0 Tank Overfill \ High -Level Sensor. Model: [3 Other ( specify equipment type and model in Section E on Page 2). 13 Other ( specify equipment type and model in Section E on Page 2). Tank In! 03 -Diesel — Tank I M In - Tank Gauging Probe. Model:_.XR_$4?3W109 [3 In - Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: VR 7$4390420 — [3 Annular Space or Vault Sensor. Model: IN Piping Sump % Trench Sensor (s). Model: VR _794300-208 13 Piping Sump \ Trench Sensor (s). Model: [3 Fill Sump Sensor (s). Model: E3 Fill Sump Sensor (s). Model: M Mechanical Line Leak Detector. Model: RJ 11640-6 0 Mechanical Line Leak Detector. Model: [3 Electronic Line Leak Detector. Model: [3 Electronic Line Leak Detector. Model: 13 Tank Overfill \ High -Level Sensor. Model: [3 Tank Overfill \ High -Level Sensor. Model: 0 Other ( specify equipment type and model in Section E on Page 2). [3 Other ( specify equipment type and model in Section E on Page 2). Dispenser IQ; 01-02 Dispenser 10- 03-04 [3 Dispenser Containment Sensor (s). Model: o Dispenser Containment Sensor (s). Model: M Shear Valve (s). Ig Shear Valve (s). 0 Dispenser Containment float (s) and Chain (s). N Dispenser Containment Float (s) and Chain (s). Dispenser IQ; 05-06 Dispenser- ID- 07-08 ❑ Dispenser Containment Sensor (s). Model: 0 Dispenser Containment Sensor (s). Model: Shear Valve (s). Shear Valve (s). M Dispenser Containment Float (s) and Chain (s), Dispenser Containment Float (s) and Chain (s). Dispenser ID- 09-10 Dispenser In.. 11-12 0 Dispenser Containment Sensor (s). Model: n Dispenser Containment Sensor (s). Model: W Shear Valve (s). M Shear Valve (s). M Dispenser Containment Float (s) and Chain (s). M 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; (cheek 811 that apply): [3 System set-up 0 Alarm history report Technician Name (print): Kris Bell Signature: Mfg. Cert.#.: B33709 — icc# 6297793 -UT License. No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2446 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 12M8113