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MONITORING SYSTEM CERTIFICATION For Use B3-All Jurisdictions Within the State of California AwhoritY Cited: Chapter 6.7, Health and Safet}-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 prepared for each monitoring stem control panel b_% the technician who performs the work. A copy ofthis torm must be provided to the tank system (Miler/operator. The m� ner/operator must submit a copy ofthis form to the local agency regulating l)'ST systems within 30 day's oftest date. A. General Information Facility Name: -----UNITED#5446 Bldg. No.: ------------- Site Address: 1403 COUNTRY CLUB BLVD - - - - _ City: STOCKTON Zip: 95204 ----- — ---- -act ity Contact Person: TOM ROBINS -- - — Contact Phone No.: (310) 930-5415 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date ofTestingiServicing: 5/1/2018 _ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: [[T�n ID: 87 Tank ID: 91 -lank Gauging Probe. Model: VR MAG 1 ® In=Tank Gauging Probe. Model: VR MAG 1 nnular Space or Vault Sensor. Model: VR 302 ®Annular Space or Vault Sensor. Model: VR 302 ping Sump/Trench Sensor(s). Model: VR 208 ® PipingSump/"French Sensor(s). Model: VR 208 ll SumpSensor(s). Model: ❑ Pill Sump Sensor(s). Modelechanical Line Leak Detector. Model: 99LD2000 ® Mechanical Line teak Detector- Model: 99LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ®lank Overfill/I ligh-Level Sensor. Model: FLAPPER ®Tank Overfill/High-Level Sensor. Model: FLAPPER –❑Other(specify equipment m t type and model ScUion F on Page 2). ❑Other(specitj equipment t}pe and model in Section E on Page 2). Tank ID: DIESEL Tank ID ® In-Tank Gauging Probe. Model: VR MAG 1 El In-Tank Gauping Probe. Model: ®Annular Space or Vault Sensor. Model: VR 303 ❑Annular Space or Vault Sensor. Modcl: ® Piping Sump/Trench Sensor(s). Model: VR 208 ❑ Pipin11 Sump/Trcnch Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: El fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: -99LD2000 ❑ Mechanical Line Leak Detector, Model: ElLlectronic bine Leak Detector. Model: El Electronic Line Leak Detector. Model: ®"Dank Overfill/High-Level Sensor. Model: FLAPPER ❑Tank Overfill/HiolrLcvel Sensor. Model: ❑Other(specifc equipment type and model in Section F on Page 2). ❑Other(specify equipment type and model in Section F.on Paoe 2)- DispenserlD 1/2 Dispenser ID: 3/4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Scnsor(s). Model: ®Shcar Valyc(s). ®Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). DispenserlD 5/6 Dispenser ID: 7/8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ®Shcar Valvc(s). ®Shcar Valve(s). ® Dispenser Containment Floats)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser►D: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shcar Vah�els) ❑Shear Vake(s). ❑ Dispenser Containment Floats)and Chain(s)_ — ❑ Dispenser Containment Float(s)and Chain(s). If the facility contains more tanks or dispensers.copy this form. Include inlormation 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, 1 have also attached a copy of the report; (check all that applt): ® System set-up ® Alarm history, report Technician Name(print): ENRIQUEAGUIRRE _ Signature: Certification No.: 634827 License. No.: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Phone No.: (951) 779-4999 _ Testing Company Address: P.O. BOX 5850, RIVERSIDE, CA 92517-5850 _ Date of Testing/Servicing: 511118