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JUN-24-2010 06:32 Service Station Systems 408 938 8888 P.04 MonitorinpSystem Equipment _ artification For Use By 111l.Jurisdietions Within The State of California 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- A separate certification or report must he 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. 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/Tesoro Bldg.No.: Site Address: 2448 W. Kettleman Ln. City: Lodi, CA Zip: 95242 Facility Contact Person: Sandy Contact Phone No.: (209) 369-3124 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 6/24/10 B. Inventory of Equipment Tested/Certified Check the appropriate hnxes to indicate specific equipment inspected/serviced; Tank iD•01-Regu Tank 1D- 02-Plus ❑ in-Tank Gauging Probe. Model:_VR 847390-107 ❑ in--rank Gauging Probe. Model: VR 847390.107 Qj Annular Space or Vault Sensor. Model: vR 744,190.409 113 Annular Space or Vault Scnsor, Model: VR 7%390409 Qj Piping Sump\Trench Sensor(s). Model: VR 794390-z00 [3 Piping Sump 1 Trench Sensor(s). Model; VR 794390.205 IX Fill Sump Sensor(s). Model: VR 794380-208 Q( Fill SkimpSensor(s). Model: VR 794380.205 Qj Mechanical tine Leak Detector. Model: Vaperless LD2000 (X Mechanical Linc L,cak Detector. Model- va oAoss L02000 ❑ Electronic I,ine I.,cak Detector. Model: ❑ Electronic Linc t.cak Detector. Model' ❑ Tank Ovcrtill\High-Level Sensor. Model: Cl Tank Overfill\High-IAvcl Scnsor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section C on Page 2). Tank ID: 03-Prem Tank I% - — 0 In-Tank Gauging Probe. Model: VR 847390-107 ❑ in- rank Gauging Probe. Modcl: Ig Annular Space or Vault Sensor. Model; VR 794390-409 ❑ Annular Space or Vault Sensor. Moder. 1% Piping Sump\Trench Sensor(s). Model: VR 794390.205 ❑ Piping Sump\Trcnch Scnsor(s). Model: IS Fill Sump Sensor(s). Model: VR 794380.208 ❑ Fill Sump Sensor(S). Model: 18 Mechanic%!Line Leak Detector. Modcl; yaportess L02000 ❑ Mechanical Line leak Detector. Model: ❑ Electronic Linc Leak Detector. Model: ❑ Electronic Linc Leak[detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: Q Tank Overfill\High-Level Scnsnr. Model: ❑ Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section F.nn Page 2). Dispenser TD; 01.02 __ Dispenser ID• 03-04 p Dispenser Containment Sensor(s). Modcl; ❑ Dispcnscr Containmcnt Scnsor(s). Model: IS Shcar Valve(s). Ix Shear Valve(s). X Dispcnscr Containment Float(s)and Chain(s). 1% Dispenser Containment Float(,;)and Chain(s). Dispenser ID* 05.06 Dispenser iD• 07.08 p Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s), Model; Shear Valve(s). IN Shear Valve(s). QS Dispcnscr Containment float(s)and Chain(s). (3 Dispenser Containment Float(s)and Chain(s). Dispenser ID• Dispenser 1D' ❑ Model: Dispenser Containment Sensor(s). Model; ❑ Dispenser Containment Sensor(s). ElShear Valve(s). ❑ Shear Valve(s). [IDispcnscr Containment Float(s)and Chain(s). 1] Dispcnscr Containmcnt Float(s)and Chain(s). "if the facility contains more tanks or dispensers,copy this form. include information for every tank and dispenser ar 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 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; (cheek all that apply): ❑ System set-up ❑ Alarm history report Technician Name(print): Randy Wilkerson Signature: r7A Mfg.Cert.g.: A32404 ICC# 5258560-UT License.No,: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 5124110