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t MONITORING SYSTEM 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, Californiao e o egu ations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report muSO&D44Q611ach 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 tNVIRONMENT AL A. General Information HEALTH DEPARTMENT Facility Name: Bonfare #35 Bldg. No.: Site Address: 15 E. Grantline Rd. City: Tracy Zip: 95376 Facility Contact Person: Sean Kapoor Contact Phone No.: (209) 833-9619 Make/Model of Monitoring System: Veeder Root TLS350 Date of Testing/Servicing: 12/05/2012 B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate snecific eauinment insnected/serviced: Tank ID: #1 Super 12000 Gal Tank ID: #2 Regular Syphon 12000 Gal ® In -Tank Gauging Probe. Model: MAGA ® In -Tank Gauging Probe. Model: MAGA ® Annular Space or Vault Sensor. Model: 794380-420 ® Annular Space or Vault Sensor. Model: 794380-420 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: E 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: E Other (specify equipment type and model in Section E on Page 2). E Other (specify equipment type and model in Section E on Page 2). Tank ID: #3 Regular 12000 Gal Tank ID: ® In -Tank Gauging Probe. Model: MAGA ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 794380-420 ❑ Annular Space or Vault Sensor. Model: E Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Piping Sump / Trench Sensor(s). Model: E Fill Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: E 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: E 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 E Dispenser Containment Sensor(s). Model: 794380-208 E Dispenser Containment Sensor(s). Model: 794380-208 E Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 enser ID: F�Dispenser E Dispenser Containment Sensor(s). Model: 794380-208 Containment Sensor(s). Model: E 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/seryiced 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 apply): ® Systeem� set-up ® Alarm history report Technician Name (print): Nikola Zagorov Signature: 1-4 r0% Certification No.: Veeder Root Level 4 # A32784 License. No.: 958763 A Testing Company Name: ECO-CHEK Compliance Testing Company Address: P.O. Box 77194, San Francisco CA 94107 Page 1 of 4 Phone No.: (888) 500-CHEK Date of Testing/Servicing: 12/05/2012 Rev (2/08)