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oniori yste Equipment?ertification 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 W V§t 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 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: 12/20/12 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 01-Regu Tank ID• 02 -Prem 0 In - Tank Gauging Probe, Model: VR 8473414-109 ® In - Tank Gauging Probe. Model: VR 847390409 ® Annular Space or Vault Sensor, Model: VR 794390.429 Annular Space or Vault Sensor. Model: VR 794390-420 3 Piping Sump \ Trench Sensor (s). Model: VR 794390208 ® Piping Sump \ Trench Sensor (s). Model:VR 794390208 ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: a Mechanical Line Leak Detector. Model: Vaporless 1.02000 Mechanical Line Leak Detector. Model: Vaporless LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ 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). Tank Ill: 03 -Diesel Tank ID: R In - Tank Gauging Probe, Model: VR 847390407 p In - Tank Gauging Probe. Model: ® Annular Space or Vault Sensor, Model: VR 794390420 ❑ Annular Space or Vault Sensor. Model: IN 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: up Mechanical Line Leak Detector. Model: RJ 148-098-e ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ 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 Dispenser ID' 03-04 ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: ® Shear Valve (s). ® Shear Valve (s). ® Dispenser Containment Float (s) and Chain (s). 0 Dispenser Containment Float (s) and Chain (s). Dispenser IIS: 05-06 Dispenser ID• 07-08 ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: Shear Valve (s). Shear Valve (s). ® Dispenser Containment Float (s) and Chain (s). ® Dispenser Containment Float (s) and Chain (s). Dispenser ID- 09-10 Dispenser ID: 11-12 ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: Shear Valve (s). ® Shear Valve (s). ® Dispenser Containment Float (s) and Chain (s). 0 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; (check aft thatapply): ❑ System set-up ❑ Alarm history report Technician Name (print): Randy Wilkerson Signature: LLg 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 96112 Date of Testing/Servicing: 12/20/12