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JUL-01-2011 08:31 Service Station Systems 408 938 8888 P.03 Monitoring System Equipment Certification For Use By All Jurisdictions Within The Slate of California Authority Cited, Chapter 6.?, Health and Surety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form trust be used to document testing and servicing of monitoring equipment. A separate certification or retsort trust be prepared for e;_ach monitoring system cQntrs)1j2angl 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(1ST system within 30 days of test date. A. General Information Facility Name: Shell/Tesoro BIdg.No.: Site Address; 2448 W. Kettleman Ln. _ City Lodi, CA Zip: 95242 Facility Contact Person, Manager Contact Phone No.: (209) 369-3124 Make/Model of Monitoring System: Gil EMC Date of Tcsting/Servicing: 5/31/11 B. Inventory of Equipment Tcstcd/Certified Check the appropriate boxes to indicate specific erlaipllteut Inspected/serviced: Tank iD-01-Regu Tank ID• 02-Prom ❑ In-Tank Gauging Probe. Model: VR 847380-107 ❑ In-Tank Gauging.,Probe. Model: VR 847300.107 ® Annular Space or Vault Sensor. Model: VR 794390404 Is Annular Spaco or Vault Sensor. Model: VR 794380408 ® Piping sump\Trench Sensor(s). Model: VR 794330-209 2 Piping Sutnp\Trench Sensor(S). Model: VR 794300.206 Irk Fill sump Sensor(s), Moder VR 7s4380•208 ® Fill Sump Sensor(s). Model. VR 7943110-206 ® Mechanical Line Leak Detector. Modci. Vaporteee LD2000 3 Mechanical Line Leak D tcetor. Model Vapertess L02000 ❑ Electronic Line Leak Detector Model: Q Llectronic I.ine Leak Detector. Modcl: ❑ Tank Overfill\Fligh•Lcvcl 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 IQ! 03-01esel Tank III• ❑ In-Tank Gauging Probe, Model: VR 447390-107 Cl in•Tank Gauging Probe. Model a Annular Space or Vault Sensor. Model: VR 794390.409 ❑ Annular Space or Vault Sensor, Model. ® Piping Sump\Trench Sensor(s), Model: VR 794380-208 ❑ Piping Sump\Trench Sensor(s) Model: ® Fill Sump Sensor(s) Model: VR 794390-205 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: Vaporioss 1.02000 ❑ Mechanical Linc Leak Detector. Model: ❑ Electronic Line Leak Detector. Model ❑ Flectronic Line Leak Detector. Model: ❑ 'fank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\I ligh-Leval Sensor. Model' ❑ Other(specify equipment type and made]in Section 8 on Page 2), C7 Other(specify equipment type and model in Section E on Page 2). Dispenser TQ- 01.02 Dispenser IQ* 03-04 ❑ Dispenser Containment Sensor(s), Model: Q Dispenser Containment Sensor W. Model: C1 Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser TD• 03.06 Dispenser ID: 07-08 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). $ Shear Valve(s). ® Dispenser Contaimncnt Float(s)and Chain(s). i$ Dispenser Containment f loat(s)and Chain(s). Dispenser Dispenser ID - ❑ Dispenser Containment Sensor(s). Modcl: ❑ 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 nr dispensers,copy this form.include information lot 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 verify that this info rotation Is correct and a Plot Plan showing the layout of monitoring equipment, For any equipment capable or generating such reports,I have also attached a copy of the; (check Nil that apply): ❑ System set-up ❑ Alarm history report Technician Name(print): Bryan Lundien Signature: Mfg.Cert.#.: B36094 iCC# 8001468•UT License,No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2445 iz Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 5/31/11