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AEGEIVEC Monitoring System Equipment Certification JUN 12 2015 1 or Use By A11.1urisdietions Within The State of California } Authority Cited:Chapter 6.7, Health and Safety Code; Chapter 16,Division 3, Title 23, California Code of;gegrda/ior7dl NMENTAi. This form must be used to document testing and servicing of monitoring equipment. A separate certification or re ori must be prepared for each monitoring system control 1anel 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: NuStar Energy Bldg.No.: Site Address: 3505 Navy Dr. City: Stockton, CA Zip: 95206- Facility Contact Person: Manager Contact Phone No.: (209) 943-5662 Make/Model of Monitoring System: Incon TS-1001 Date of Testing/Servicin 5113/15 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID•o1-Diesel Tank ID: ❑ In-Tank Gauging Probe. Model: Cl In-Tank Gauging Probe. Model: to Annular Space or Vault Sensor. Model. Incon TSP.P,15 ❑ Annular Space or Vault Sensor. Model: 19 Piping Sump\Trench Sensor(s). Model: Incon TSP V L4 ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector. Moder ❑ Mechanical line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: I ❑ f-ectronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill'%High-Level Sensor. Model: a Other(specify equipment type and model in Section F,on Page 2y Cl Other(specify equipment type and model in Section F on Page 2) Tank IQ: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model. p Piping Sump\Trench Sensor(s), Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model:_ ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Levet Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section L on Page 2) ❑ Other(specify equipment type and model in Section f-.on Page 2). Dispenser IDw Dispenser[Do ❑ Dispenser Containment Sensor(s). Model. ❑ Dispenser Containment Sensor(s). Model. p Shear Valve(s) ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(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). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model p Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s) p 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/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; (checkall ihatapply): ❑ System set-up ❑ Alarm history report Technician Name(print): Myke Briggs Signature: Ye — Mfg.Cert.#.: 4/2(, 1�2 76 1 TCC# 8033115-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: 5113/15