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.RECEIVED 0 0 U,PC 2 3 2013MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California REC@_ Ec'= r e .6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This forrRiMPAMWOESument testing and servicing of monitoring equipment. A separate certification or report must ] d= eple3 Qe@h 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 systems within 30 days of test da a A. General Information HEALTH DEPARTMENT l.- Facility Name: Bonfare #35 Site Address: 15 E. Grant Line Road Facility Contact Person: Russ Make/Model of Monitoring System: Veeder Root TLS350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Bldg. No.: City: Tracy, CA Zip: 95376 Contact Phone No.: (209) 833-9619 Date of Testing/Servicing: 12/10/2013 Tank ID: #1 Super 12000 Gal TankID: #2 Regular Syphon 12000 Gal Z In -Tank Gauging Probe, Model: MAGA Z In -Tank Gauging Probe. Model: MAGA Z Annular Space or Vault Sensor. Model: 794380-420 Z Annular Space or Vault Sensor. Model: 794380-420 Z Piping Sump / Trench Sensor(s). Model: 794380-208 Z Piping Sump / Trench Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 794380-208 Z Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector, Model: Z Electronic Line Leak Detector, Model: VR Series 8484 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: Z Other (specify equipment type and model in Section E on Page 2). Z Other (specify equipment type and model in Section E on Page 2). Tank ID: #3 Regular 12000 Gal Tank ID: Z In -Tank Gauging Probe. Model MAGA ❑ In -Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794380-420 ❑ Annular Space or Vault Sensor. Model: Z Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Piping Sump / Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: VR Series 8484 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: Z 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: 1-2 Dispenser ID: 3-4 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: Z Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ 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). *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 manufacturers' 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 applv): ® System set-up ® Alarm history report Technician Name (print): Nikola Zagorov Signature: r oV Certification No.: Veeder Root Level 4 # A32784 License. No.: 958763 A Testing Company Name: ECO-CHEK Compliance Phone No.: (888) 500-CHEK Testing Company Address: P.O. Box 77194, San Francisco CA 94107 Date of Testing/Servicing: 12/10/2013 Page 1 of 4 Rev (2/08)