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RECEIVrb MONITORING SYSTEM CERTIFICATION SEP 1 12017 For Use B�F All Jurisdictions Within the State ol'California Authority Cited: Chapter 6.7,Health and Sqlivtv Code: Chapter 16, Division 3, Title 23, Califor-nia Code of'Re-tilations ENVIRORMENTAL HEALTH This tbrm must be used to document testing and servicing of monitoring equipment. A separate certification or report AMMOUR*98SA-1 tnonitoriut sy%tem control pane)by the technician who performs the work. A copy of this form must be provided to the tank system own et*.,,'()Pcra tor. The 01MICr/Operatol"must Submit a copy of this form to the local agency regulating UST systems within 30 days of test dale. A. General Information Facility Name:United Pacific 5447 Bldg.No.: Site Address: 1469 E.Hammer Ln. City. Stockton —_ Zip: 95210 Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System:Veeder-Root TL.S-350 Date of Testing/Servicing:9/612017 R. Inventory of Equipment Tested/Certified Check the neerop-late boxes to indicate,specific equipment inspected/serviced Tank ID:Diesel Tank ID: ❑In-l'ank Ganging Probes Model: E]In-Tank Gauging Probe. ModcL ❑AMIL11111-Space 01 Vault Sensor. Model: 794390-409 n Annular Space or Vault Sensor. Model: El Piping Sunip;Trench Scilsol(s). Model: rl Piping Sunip r Trench Sensor(s). Model, Fill Sunip Sensor(.). Model: C]fill Sump Sensoqs). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Fhxtronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/I ligh-Level&nsoi. Model: 0 Tank Overfill/lligh-Level Sensor. Model: C1 Other(spv.city equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section L on Ngc 2). Took ID: Tank ID: n hi-Tank Ganging Probe, Model: 0 hi-Tank Gauging Probe. Model: E]Annular Space of Vault Sensot, Model: 0 Annular Space or Vault Sensor, Model: ❑Piping Sunip/Trench Scrisor(s). Model: E3 Piping Surnpi Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑ Fill Sump Solsor(s). Model: I nMechanical Line Leak Delcelor, Model: E]Mechanical Line Leak Detector. Model: ❑Flecirovic Line Leak Detector. Model: E]Electronic Line Leak Detector. Model: ❑Tank Overfill,'High-Level Sen,,ot% Model: ❑Tank Overfill i I liph-txvel Senor. N'lodel: Fj Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section F.on page 2). Dispenser 11): Dispenser ID: Model: ❑Dispenser Containment Sensor(&). Model: 0 Shear Valve(s), ❑Shear Valve(s). E]Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). D is p enser ID: Dispenser ID: E Model: ❑Dispenser Co nt ainment Sensorls). Mo del. sh��ar valve(0. ❑Shear Valvv(s), 0Dispcaser Containment Float(s)and Chain(s). EDispenser Containment Floats)and Chain(s ). Dispenser ID: Dispenser ID: E Model• CDispenser Containment Scnsor(%). Model: FShear vadvv'). FShear Valve(s). [ Disp.n,er Containamit Float(s)and Dispenser Containment Float(s)and Chani(s). flfthe facility contains store 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 mail ufact urers 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): [E],System set-up [:]Alarm history report Technician Name(print):Pat Armour Signature:4 Certification No.: A20284,8141940-UT License.No.: 499721 Testing Company Name: Armour Petroleum Set-vice&Equipment Cortioratioll Phone No.:(707)43 7-6668 Testing CompanyAddress:240()Cement Hill Rd.,B3,Fairfield,CA 94533 Date of Testing/Servicing:9/612017 Page I of 3 Rev(21'08) In -)