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f-1AY'-28-2010 1953 Service Station Systems 408 936 8882 P.05 -MonitorinflSystem Equipment irtification For Use By All.1urisdictions 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 triust be used to document testing and servicing of monitoring equipment. Apar3t secertification or report rz? St 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. 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: Contact Phone No.: (209) 369-3924 Make/Model of Monitoring System: Date of Tcsting/Servicing: 4/30110 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank1Q., Tank ID L -.162 ❑ In-Tank Gauging Probe. Model: ❑ in-'lank Gauging Probc, Model: & Annular Space or Vault Sensor. Model: d`' OvC0.nnular Space or Vault Sensor. Modcl: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: l7 Mechanical Linc Lcak Detector. Model: ❑ Mechanical Line Lcak i?ctector. Model: p Electronic tine Lcak Detector. Model: ❑ Electronic Line Leak Dctcctor. Model: C] Tank Overfill\High-I.,cvcl Sensor. Model' ❑ tank Overfill\I ligh-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* T V1 Tank i% El In-Tank Gauging Probe- Model. ❑ In-Tank Gauging Prohe. Model; g Annular Space or Vault Sensor, Model: yas_ ❑ annular Space or Vault Sensor, Model: ❑ Piping Sump\'french Sensor(s). Model: ❑ Piping Sump\ french Sensor(s). Model: ❑ Fill Sump Sensor(s). Model; ❑ fill Sump Sensor(s). Model. ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical line Leak DCTCCtOr. Model: ❑ Flectmnic Line Leak Detector, Model: ❑ Electronic Linc Leak Detector. Model: ❑ Tank Overfill\Fligh-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor Model. ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify cquipmcnt type and model in Section E on Page 2). Dispenser ID• Dispenser iQ: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispemer Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear valve(s). p Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID• Dispenser ID ❑ Dispenser Containment Sensor(s). Model: p Dispenser Containment Sensor(s), Model: ❑ Shear Vaive(s). ❑ Shear Valve(s). ❑ Dispenser Containment Fluat(s)atnd Cltain(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). ❑ Diaperner 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 - f certify that the equipment identified in this document.vas 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 �rc� Lyy �- I' Technician Name(print): Signature: - Mfg. Cert.tt.: 83LiD9N' icc# aT 1-icense.No.: 312844 Testing Company Name. Sly C-S`M77GY1STEYh 5 Phone No.: (408) 971-2445 -resting Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of 7'esting/Servicing: 4/30110