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R CENVIE <br /> 'USI 07 Z018 <br /> Monitoring System Equipment Certifleatinn.;0NMEN`AL <br /> For Use By All Jurisdictions Within The State of California HF TH DEPARTMEW <br /> Authority Cited:Chapter 6.7,Health and Safety Code; Chapter 16,Division 3, Title 23, California Code of Regulations <br /> This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be <br /> prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided <br /> to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST system <br /> within 30 days of test date. <br /> A. General Information <br /> Facility Name:NuStar Energy Bldg.No.: <br /> Site Address: 3505 Navy Dr. City: Stockton, CA Zip: 95206- <br /> Facility Contact Person: Manager Contact Phone No.: (209) 943-5662 <br /> Make/Model of Monitoring System: Incon TS-1001 Date of Testing/Servicing: 5/9/18 <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicate specific equipment inspected/serviced: <br /> Tank 1%01-Diesel Tank ID• <br /> ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> ® Annular Space or Vault Sensor. Model: Incon TSP-ODS ❑ Annular Space or Vault Sensor. Model: <br /> ® Piping Sump\Trench Sensor(s). Model: Incon TSP-uLS ❑ Piping Sump\Trench Sensor(s). Model: <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: <br /> ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Pace 2). <br /> Tank IR& Tank ID: <br /> ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: <br /> ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: <br /> ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: <br /> ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). <br /> Dispenser ID: Dispenser 10• <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). p Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID• <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID• <br /> ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑ Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> *If the facility contains more tanks or dispensers,copy this form.Include information for every tank and dispenser at the facility <br /> C.Certification- I certify that the equipment identified in this document was inspected/serviced in accordance with the <br /> manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verify that this <br /> information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such <br /> reports,I have also attached a copy of the; (ckerk all that apply): ❑ System set-up ® Alarm history report <br /> Technician Name(print): Myke Briggs Signature: <br /> Mfg.Cert.#.: 1002583708 ICC# 8033115-UT License.No.: 485184 <br /> Testing Company Name: Service Station Systems Phone No.: (408)971-2445 <br /> Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 5/9/18 <br />