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P7hrsk1mil MONITORING SYSTEM CERTIFICATION or Use By All Jurisdictions Within the State of Cali;. j 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. If more than one monitoring system control panel is installed at the facility,a separate certification or report must be prepared 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. a owner operator must submit a copy of this form tot the local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: ULTRAMAR#696 City. LODI CA Zip:95242 Site Address: 2448 W. KETTLEMAN LANE Contact Phone No:369-3124 LOWER SACRAMENTO RD. Facility Contact Person: MGR-BETH/ASST MGR-MIKE Date of Testing/Service: 09/12/2001 Make/Model of Monitoring System: GILBARCO EMC Work Order Number: 2218420 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seryiced Tank ID SUP TanklD: PLS In-Tank Gauging Probe. Model: CAP PROBE 71 In-Tank Gauging Probe. Model: CAP PROBE Annular Space or Vault Sensor. Model: LIQUID SENSOR X Annular Space or Vault Sensor. Model: LIQUID SENSOR Piping Sump/Trench Sensor(s). Model: LIQUID FLOAT LIQUID FLOAT Piping SumplTrench Sensor(s). Model: Fill Sump Sensor(s). Model: LIQUID FLOAT LIQUID FLOAT X Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FXIV X FXIV Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 61 SO X Tank OverfilUHigIn-Level Sensor. Model: 61 SO 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 71 In-Tank Gauging Probe. Model: CAP PROBE In-Tank Gauging Probe. Model: 79 Annular Space or Vault Sensor. Model L Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: LIQUID FLOAT Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: LIQUID FLOAT Fill Sump Sensor(s). Model: 71 Mechanical Line Leak Detector. Model: FXIV Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 61SO 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: 11b 71 Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: ® Shear Valve(s). ShearValve(s) ® Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). lspenser lspenser lu. 7 Dispenser Containment Sensor(s) Model Dispenser Containment Sensor(s). Model ® Shear Valve(s). 7 Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 1-1 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/seryiced 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; ® 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