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M onitoring System Equipment CertificationJUN 01 2016 For Use By All Jurisdictions IMthin The Sate of California Authority Cited.,Chapter 6.7, Health and 5afetyCodq- Chapter 96, Division 3, Title 23, California Code off ufa ,•� {.� A .. This form must be used to document testing and servicing of monitoring equipment. A separate cetification or&port must be prepared for each monitoring system control panel by the technician who performs thework. 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 I nfermaticn Facility Name: NuStar Energy Bldg. No.: SiteAddress 3505 Navy Dr. City: Stockton, CA Zip: 95206- Facility Contact Person: Manager Contac Phone No.: (209)943-5662 Make/Model of Monitoring System: Incon TS-1001 Dateof Testing/Servicing: 513116 B. Inventory cf Equipment TestedlCertified Check the appropriate boxes to Indicate spedfic equipment inspectediserviced: Tank IQLo1-Diesel Tank ID: ❑ In-Tank Gauging Robe- Model: ❑ In-Tank ® Annular (�a�ngR°� Model: Space or Vault Sensor. Model: Incon TSP- ,L S C) Ar�ndar Space or Vadt Sensor. Mode: no Rpi ng Sure 1 Trench Sensor(s). M odd: icon TSP-uc.s ❑ Rping Sump 1 Trench Sensor(s). M odd: ❑ FII Sump Sensor(s). Mold: ❑ FtII Sump Sensor(s). Model: ❑ Merhanlcel Line Leek Detector- Model: ❑ MednanicalLine LeakDetector. Model: ❑ Flectronicl_ineLeak:Detector. Model: ❑ Electronic Line LeakDeleifur. Model: ❑ Tank Overfill 1 High-Level Serer. Model. ❑ Tank Overfill 1 High-Level Sonsor. Model: N Other(spedfy equipment type and model i n Section E on Pale 2). ❑ Other(sped f Y slut PrT>err<type and readerl i n Sadi on E on Page 2). Tank IQ; Tank ID: ❑ In-Tank Gaging Robe. Model: ❑ In-Tank Gahgnng Rabe. Model: ❑ Annuls Space or Vault Ssnsor. Model: ❑ Amuhlar Space or Vadt Sensor. Model: ❑ Piping Sump 1 Trench Sensor(s). Modd: ❑ Rprig Sump 1 Trench Sensor(s). Model: ❑ Fill Sump Sanson(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mednat cal Line Leak Detector. Mold:_ ❑ Mechanical Line Leak Detector. Model: ❑ ElectronlcLine Leak Detector. Model: ❑ Electronic Lire Leek Detector. Model: ❑ Tank Oveffill t High-Level Sensor. Model: ❑ Tank Overfill 1 High-Level Se nsx, Model: ❑ Other(spedfy equipment type and model in Sacion E on Page2). ❑ Other(spa9fy eq pment type aid model in Section E on Pale 2). Dispenser IQ; Dispenser I D: ❑ Dispenser Contanment Seng(s). Madel: ❑ Dispenser Contalnvnart Sensor(s). Model: ❑ Shea-V alve(s). ❑ S>ear V al ve(s). ❑ Dispe nser Containment Float(s)aid Chain(s). ❑ Dispenser Containment Roat(s)and Chan(s). Dispenser I D: n DispenserContaen nrnentSenscr(s). Model: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Sphere Valve(s), ElDispense Containment Flom(s)and Chan(s). ❑ Dispenser Vver(s). L] spansa Containment Float(s)and Chain(s). Direr I D: Dispenser I D: ❑ DiTer� Dispenser Containment Sensor(s). Model: ❑ Dir Continmernt Sernsor(s). Model: ❑ Shea V alve(s). E] Shea V al ve{s). ❑ Dispenser Containment Floc(s)and Chan(s). ❑ Disperw Contarxmerg Float(s)and Chain(s)- I f the fad I i ty contai ns more tanks or di spensas,copy this form.Include information for every tank and dispenser at the facility C.C tifieation- 1 certify that the equipment identified in thisdoament was inspectedlserviced In aocordance with the manufacturer'sguideiines Attached to this Certification isirtforrnation(ag manufactures;checklists)necessarytoverify that this lnfermahoh is correct and a Plot Plan shaMngthe layout of monitoringequlpmertt- For arty equipmert capable of gawatingsuch reports,I have also attached a copy of the (cheek all that apply): ❑ System set-up ❑ Alarm history report Technician Name(print): Kris Bell Signature: Mfg.Cert.#.: `�613Y'5V370 g ICC# 5297793-UT License. No.: 485184 Testing Company Name: Service Station Systems PhoneNo.: (408)971-2445 Testing Company Address 680 Quinn Ave.,San Jose,CA 95112 Date of Testing/Servicing. 513116