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, T 0 SystemMonitoring For Use By All Jurisdictions Within The State of California A U G 2 7 2018 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 separate certificationo L prepared for each monitoring_system control panel by the technician who performs the work. A copy of thi*WWffiK09-VAWMENT 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:H&M Market Bldg.No.- Ci Escaton,CA Zip: 95320- Site Address: 2501 Jackson Ave. Facility Contact Person: Manager Contact Phone No.: (209}838-3971 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 7131118 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank Tank ID 07-Regu Tk IIZ.02-Prem p In-Tank Gauging Probe. Model: VRO41390-107 ❑ In-Tank Gauging Probe. Model: VR 847390-107 i� Annular Space or Vault Sensor. Model: VR 7943-30426 ® Annular Space or Vault Sensor. Model:--VR 794390-420 Piping Sump\Trench Sensor(s). Model: VR 794386.208 Ig Piping Sump\Trench Sensor(s). Model: vet 794380.208 11[IFill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Modal: ® Mechanical Line Leak Detector. Model: RJ 116455.5 ® Mechanical Line Leak Detector. Model: yaporless L02066 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank I . 03-Diesel Tank IIf, p In-Tank Gauging Probe. Model: VR 84730o-t07 (IIn-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 794390420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump\Trench Sensor(s). Model: VR 794380.208 ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: [3 Fill Sump Sensor Leak Detector. Model: Model: 01 Mechanical Line Leak Detector. Model: RJ 448.658-s ❑ Mechanical Line Le [3 Electronic Line Leak Detector. Model: p Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Dispenser ID 01.02 Dispenser ID° 03-04 [I Dispenser Containment Sensor(s). ModelShear: ❑ Containment Sensor(s). Model: ® 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). Modal ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID- Dispenser ID• ❑ [IDispenser 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 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; (check alt that apply): ® System set-up ® Alarm history report Technician Name(printZ Randy Wilkerson Signature: L104 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: 7131118