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R MONITORING SYSTEM CERTIFICA'I'IO For Use By All Jurisdictions Within the State of CaliforniaEC t ED Authority Cited: Chapter 6.7,Health and Safety Code; Chapter 16, Division 3, Title 23, Californi C ons This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be ar d for each monitorine system control panel by the technician who performs the work. A copy of this form must be provided to the tank systeWb The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information ENVIRONMENTAL HEALTH Facility Name: Bonfare Market#35 Bldg.QEPARTMENT Site Address: 15 E.Grant Line Road City: Tracy,CA Zip: 95376 Facility Contact Person: Varinder Pal Singh Contact Phone No.: (209) 481-4099 Make/Model of Monitoring System: Veeder Root TLS350 Date of Testing/Servicing: 12/06/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: #1 Super 12000 Gal Tank ID: #2 Regular Syphon 12000 Gal Z In-Tank Gauging Probe. Model: MAGA Z In-Tank Gauging Probe. Model: MAG-1 ®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 apply): Z System set-up Z Allarrm history report Technician Name(print): Nik Zagoroy Signature: Iy?L21,1 71r c>V Certification No.: Veeder Root Level 4#A32784 License.No.: 958763 A Testing Company Name: ECO-CHEK Compliance, Inc. Phone No.:(888) 500-CHEK Testing Company Address: P.O. Box 1394, Lafayette,CA 94549 Date of Testing/Servicing: 12/06/2016 Page 1 of 4 Rev(2/08)