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MONITORING SYSTEM CERTIFICATION '97k1 0hWjYor Use By All Judsdicdons Within the State of Califft Authority Cited:Chapter 6lWalth and Safety Code;Chapter 16,Division 3 Title alifomia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility,a separate certification or report must he prepared for each monitoring system°Omml panel Is orm to t eythe technician v4ho performs the laced agency regulating UST systems vn hinn 30 days of test date.rk. A copy of this form must be provided to the tank sys em ovmer operator. a ovmer operator must su mit a copy A.General Information City: TRACY CA Zip:95376 Facility Name: ULTRAMAR 698 Contact Phone NO:832-8815 Site Address: 153 E 11TH ST Date of Testing/Service: 03/20/2002 Facility Contact Person: MGR-CHEIA Make/Model of Monitoring System: GILBARCO EMC Work Order Number: 2221561 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: SUP Tank ID: REG 1 In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping SumplTrench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensm(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: EXTERNAL X Tank Overfill/High-Level Sensor. Model: EXTERNAL Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). an an In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Senores. Madel: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: 71 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). Ispenser Dispenser Containment Sensors) Model: Dispenser Containment Sensor(s) Model: Shear Valve(s) Shear Valve(s). Dispenser Containment Floats)and Chain(s). Dispenser Containment Float(s)and Chain(s). Ispenser Ispenser Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear VaNe(s). Dispenser Containment Floats)and Chain(s). Dispenser Containment Floats)and Chain(s). Dispenser lD: DispenserlD: Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: QShear 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 Site 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 report; F� Alarm history report PRINTED NAME: MICHAEL T LEVESQUE SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01