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JUL-05-2007 03:40 Service Station Systems 408 938 8888 P.O2 Monitorik.„,; System Equipment _"ertification For Use By All Jurisdictions Within The State of California Authority Cited- Chapter 6 7, Health and Safety Code; Chapter /6, 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 b� ,re aced for elicit 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: USA 68222 Bldg. No.: Site Address: 2132 Mariposa Rd. @ Farmington Rd. City: Stockton, CA Zip: 95205 - Facility Contact Person: Manager Contact Phone No.: (209) 946-9282 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 614/07 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 01-Regu Tank ][D• 02 -Plus (g In - Tank Gauging Probe. Model: VKU7345-107 pI In - Tank Gauging Probc. Model; VR ea7390.107 M Annular Space or Vault Sensor. Model: Ronan 1.91-3 _ 3 Annular Space or Vault Sensor. Model: Ramn tss 0 Piping Sump \ Trench Sensor (s). Model: VR 7843ao.ma IX Piping Sump \ Trench Sensor (s). Model: VR 7943110.2011 m Fill Sump Sensor (s). Model: _ VR 724389.2011 (X Fill Sump Sensor (s). Model VR 794390-209 11 Mechanical Line Leak Detector. Model: list i I"S74 (x Mechanical Line Leak Detector. Model: 1C)1111Y67S ❑ Electronic Linc Leak Detector. Model: Nene --[3 Electronic Line Leak Detector. Model: Nag. 13Tank Overfill \ High -Level Sensor. Model: Na.a, p Tank Overfill \ High -Level Sensor. Model: Nww ❑ 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•a3-Prem Tank ID: 04-DieselIX In - Tank Gauging Probe. Model: VR 847399.107 13 In - Tank Gauging Probe. Model; VR6473 107 Is Annular Space or Vault Sensor. Mode]: R.mn t rXas� Annular Space or Vault Sensor. Model;Ragan 1.5.5[XPiping Sump \ Trench Sensor (s). Model: vR 79438* -208 G9 Piping Sump \ Trench Sensor (s). ModcL vR7a3ee.2aIg Fill Sump Sensor (s). Model: VR794380-208 IL 3 Fill Sump Sensor (s). Model: VR 7943MNBQ Mechanical Line Leak Detector Model: R31194s7-s Qt Mechanical Line Leak Detector. Model: Rd 118.067.8 (3Electronic Line Leak Detector. Model: Nene Q Electronic Line Leak Detector. Model: None (3Tank Overfill \ High -Level Sensor. Model: None E] Tank Ovcrtill \ High -Levi l Sensor. Model: Nona [3 Diner ( specify equipment type and model in Section E on Page 2). r3 other ( specify equipntmt type and mmlel in Section E on Page 2). Dispenser 1D• 01-02 _ Dispenser 04-05 CK Dispenser Containment Sensor (s). Model: VR 70011 m _ RI Dispense Containment Sensor (s). Model: VR 7943/10308 13 Shear Valve (s). IN Shear Valve (s). E3 Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 05- _ Dispenser l.- 07.08 IN Dispenser Containment Sensor (s). Model. yR7114390-208 _ ❑ Dispenser Containment Sensor (s). Model: VR 79439030/1 Shear Valve (s). Cl Sheat Valve (s). ❑ Dispenser Containment Float (s) mid Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID. 09-10 Dispenser ID• 11- ❑ Dispenser Comainmcnt SCn9*r (3). Model: VR 794390-208 ❑ Dispenser Containment Sensor (s). Model: V1179,13110-208 ❑ 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 verifv 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): IE System set-up M Alarm history report Technician Name (print): Randy A Wilkerson Signature: /U19L_. Mfg. Cert.#.: A32404 ICC# 5258560 -UT License. No.: 485184 Testing Company Name Serv. Sta. Sys. Phone No.: (408) 971-2445 Site Address: 2132 Mariposa Rd. _ Farmington Rd. Date of Testing/Servicing: 614/07