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MONIARING SYSTEM CERTIFI�TION For Use By All Jurisdictions Within the State of Cali nia JUL 2 Authority Cited.• Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code o},R,e mations EiUiRONi�"E This form must be used to document testing and servicing of monitoring equipment. A separate certification or r ed or each monitoring system control panel by the technician who performs the work. A copy of this form must be rout ed to the tank system owner/operator. 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 Facility Name: MANTECA SHELL Bldg. No.: Site Address: 824 E.Yosemite Avenue City: Manteca Zip: 95336 Facility Contact Person: Ernie Song Contact Phone No.: (209) 825-7722 Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 4/30/2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific eq ui ment ins ected/serviced: Tank ID: T1: Unleaded Tank ID: T2: Unleaded Plus ❑In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: PA02591144000 E Annular Space or Vault Sensor. Model: PA02691144000 split tank E Piping Sump/Trench Seasor(s). Model: PA02592000000 E Piping Sump/Trench Sensor(s). Model: PA02692000000 ❑Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: WMI 99LD2000 E Mechanical Line Leak Detector. Model: VMI LD-2000 ❑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 ID: T3: Super Unleaded Tank ID: ❑In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: PA02691144000 split tank ❑Annular Space or Vault Sensor. Model: E Piping Sump/Trench Sensor(s). Model: PA02692000000 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Season(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: VMI LD-2000 ❑Mechanical tine Leak Detector. Model: ❑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). Dispenser ID: 1 & 2 Dispenser ID: 3 & 4 E Dispenser Containment Scnsor(s). Model: PA 02890320 E Dispenser Containment Sensor(s). Model: PA 02890-320 E Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7& 8 ®Dispenser Containment Sensor(s). Model: PA 02890320 ® Dispenser Containment Sensor(s). Model: PA 02890320 E Shear Valve(s). E 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): ®System set-up ®Alarm history report Technician Name Guadalupe Sanchez Signa Certification No.: A30138 License. No.: 883706 Testing Company Name: Reliable Petroleum Services Inc. Phone No.:(209) 845-8586 Testing Company Address:521 Branding Iron Street Oakdale CA 95361 Date of Testing/Servicing: 4/30/2009 Page 1 of 4 UN-036-1/5 n .unidocs.org Rev.01/17/08