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APR -26-2012 09:18 Service Station Systems 408 938 ee88 P.03 0 10 • Monitoring System Equipment 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 s to cerci hication or repart must be re aced for each mciaitojilig sxg= control panel by the technician who performs the work. A copy of this forst 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.: 1209) 473-7337 Make/Model of Monitoring System: V/R TLS -350 B. Inventory of Equipment Tested/Certifted 9-6.....11 µ-......renAam Mrea to indicate enacifir rauinment insneeted/serviced: Date of Testing/Scrvicing: 3129112 "if the facility contains more tanks or dispensers, copy dtis form. Include information for every tank and dispenser at the facility C. CelrtifiCatiOn - 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; (chock all dtatspplyl: ❑ System set-up O Alarm history report Technician Name (print): Randy Wilkerson Signature: Mfg. Cert.#.: A32404 TCC# 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: 3129112 Tank ID• 01 OU Tank ID• 02 -Prem (j in - Tank Gauging Probe. Model: VR 8473WIC9 _ ❑ in . Tank Gauging Probe. Model: 847390-109 W Annular Space or Vault Sensor. Model: VR 794390$20 a Annular Space or Vault Sensor. Model: VR 794390.4.20 0 Piping. Sump \ Trench Sensor (a). Model: VR 794380.208 0 Piping Sump \ Trench Sensor W. Model; vR 794340.208 p Fill Sump Sensor (s). Model: _ ❑ Fill Sump Sensor (s). Model: % Mechanical Line Leak Detector. Model: Vagortess LOOM ® Mechanical Line Leak Detector. Model: Vmmdeae LDJO ❑ Electronic Linc Leak Detector. Model: La Electronic Line Leak Detector. Model: Cc Tank Overfill \ High-level Sensor. Model: VR 7$0991.001 ® Tank Overfill \ High -Level Sensor. Model; VR 190091401 ❑ Other ( specify equipment type and model in Section E on Page 2). [3 Other ( specify equipment type and model in Section E on Page 2), Tank III. 03 -Diesel 'Tank 13 II?• In - Tank Gauging Probe, Model: ❑ In • Tank Gauging Probe. Model; VR 3473 407 2 Annular Space or Vault Sensor. Model: VR 794390-42D Cl Annular Space or Vault Sensor. Model: M Piping Sump \ Trench Sensor (s). Model: VR 794380-205 ❑ Piping Sump \ Trench Sensor (s). Model: a Fill Sump Sensor (s). Model; p Fill Sump Sensor (s). Model: Z Mechanical Line Leak Detector. Model; RJ 10411M [3 Mechanical Line Leak Detector. Madcl: p Electronic Line Leak Detector. Model: p kiectrvnic Line Lusk Detector, Model: 0 Tank Ovefll \ High•Levcl Sensor. Model: VR 79MI-001 ❑ Tank OvCrFjll \ High -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section F., on Page 2). p Other ( specify equipment type and model in Section E an Page 2). Dispenser IIS; -01.02 Dispenser ID• 03-04 L] Dispenser Containment Sensor (s). Model; [3 Dispenser Containment Sensor (s). Model: ® Shear Valve (s). M Shear Valve (s), Dispenser Containment Float (s) and Chain (s). 0 Dispenser Containment Float (s) and Chain (s). Dispenser IDI 05 _ _ Dispenser II)a 07-08 13 Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: 11 Shear Valve (s). 0 Shear Valve (s). ® Dispenser Containment Float (s) and Chain (s). 0 Dispenser Containment Float (s) and Chain (s). Dispenser IQ! 0940 Dispenser IDs 11-12 ❑ Dispenser Containment Sensor (s). Model: G3 llispenser Containment Sensor (s). Model: 11 Shear Valve (s). I$ Shur Valve (a). 0 Dispenser Containment Float (s) and Chain (s). Dispenser Containment Float (s) and Chain (s). "if the facility contains more tanks or dispensers, copy dtis form. Include information for every tank and dispenser at the facility C. CelrtifiCatiOn - 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; (chock all dtatspplyl: ❑ System set-up O Alarm history report Technician Name (print): Randy Wilkerson Signature: Mfg. Cert.#.: A32404 TCC# 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: 3129112