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Monitoring ystem Equipment 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, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be nreoared for each 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 system within 30 days of test date. A. General Information Facility Name. Cie,,tori Bldg.No.: Site Address: 6633 Pacific Ave City: Stockton,CA Zip: 95207-3719 Facility Contact Person: Manager Contact Phone No.: (209)477-4294 Make/Model of Monitoring System: V/R TLS-350 Date of Testing/Servicing: 3115110 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:01-Prem Tank ID• 02-Regu ❑ In-Tank Gauging Probe. Model: VR 547390-107 ❑ In-Tank Gauging Probe. Model: VR 547390-107 I% Annular Space or Vault Sensor. Model: VR 794350-301 11 Annular Space or Vault Sensor. Model: VR 754380-301 Qj Piping Sump\Trench Sensor(s). Model: VR 794380.208 IN Piping Sump\Trench Sensor(s). Model: VR 794380-205 IN Fill Sump Sensor(s). Model: VR 794380.208 Q( Fill Sump Sensor(s). Model: VR 794380.208 ❑ Mechanical Line Leak Detector, Model: Cl Mechanical Line Leak Detector. Model: Q( Electronic Line Leak Detector. Model: vR Was 84x4 Il Electronic Line Leak Detector. Model: vR Wee 8484 ❑ Tank Overfill\High-Levet 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 ID• 03-Regu Tank ID• ❑ In-Tank Gauging Probe. Model: VR 8473"407 ❑ In-Tank Gauging Prom. Model: C1 Annular Space or Vault Sensor. Model: VR 7N380a01 ❑ Annular Space or Vault Sensor. Model: Piping Sump\Trench Sensor(s). Model: VR 794380-208 ❑ Piping Sump\Trench Sensor(s). Model: M Fill Sump Sensor(s). Model: VR 794380.208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Ig Electronic Line Leak Detector. Model: VR sates 8484 ❑ 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). Dispenser ID• 01-02 Dispenser ID: 03-04 I% Dispenser Containment Sensor(s). Model: vR 794380.208 11 Dispenser Containment Sensor(s). Model: VR 794380-208 IS Shear Valve(s). IN Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05-06 Dispenser ID: 07-08 IS Dispenser Containment Sensor(s). Model: VR 794380-208 13 Dispenser Containment Sensor(s). Model: VR 794430-20 Q( Shear Valve(s). 13 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser IQ: 06--10 Dispenser ID: 11-12 IN Dispenser Containment Sensor(s). Model: vR 794380.208 M Dispenser Containment Sensor(s). Model: VR 794380-208 M Shear Valve(s). IN 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 all that apply): ❑ System set-up ❑ Alarm history report Technician Name(print): Randy Wilkerson Signature: Mfg.Cert.#.: A324O4 ICC# 5258560-UT License.No.: 485184 Testing Company Name: Sery-Sta.S)►s. Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 95112 Date of Testing/Servicing: 3115110