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MAR-21-2012 12:22 Service Station Systems 408 938 8888 P.03 Monitoring System Equipment Certification For Use lay All Jurisdictions Within The State of California Authority Cited: Chapter 6.7,Health and Safety Code;Chapter 16, Division 3, Title 13, California Code of Regulations This form must be used to document tasting and Servicing of monitoring equipment. A separate certification or renart must bg nmoared for each mtmiWring system control nand 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: 401 W. Kettleman Ln. City: Lodi,CA Zip: 95240 Facility Contact Person: Mike Contact Phone No.: (209)368-8787 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 2/23/12 % Inventory of Equipment Tested/Certified Cheek the appropriate boxes to indicate specific equipment inspected/serviced- Tank t!).01-Regu Tank 1Q,;!2_-Prom 13 in-Tank Gauging Probe. Model: VR 8473NA 07 E3 In-Tank Gauging Probe. Model: VR 1347390-107 ill Annular Space or Vault Sensor, Model: VR 794390+120 0 Annular Space or Vault Sensor. Model: VR 74!890.320 Cl piping Sump\Trench Sensor(s). Model: yR 794390499 M Piping Sump\Trench Sensor(s). Model: VR 793380-M p Fill Sump Sensor(s). Madel: p Fill Sump Sensor(s), Model: 0 Mechanical Lane Leak Detector. Model: RJ 115-9114-5 0 Mechanical Line Look Detector. Model: R31164583 p Electronic Line Leak Detector. Model: O Electronic Lina Leak Detector. Madel: p 'tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: _ ❑ Other(specify equipment type and model in Section E on Page 2). p Other(specify equipment type and model in Sonion E on Page 1). Tank l.DL rank 1D: ❑ in-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model; ❑ Annular Space or Vault Sensor. Model: (3 Annular Space or vault Sensor. Model; [] Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: p Fill Sump Sensor(s). Model: p Mechanical Line leak Detector. Madel: Q Mechanical Line Leak Detector, Model: Q illaurunic Line Imak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: Q Tank Overfill\High-Level Sensur. Model: Q Other(specify equipment type and model in Section 11-on Page 2). 0 Other(specify equipment type and model in Section rs on Pago 2). Dispenser Ii); 01.02 Dispenser 1D• 03-04 p Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: a Shear Valve(s). Shear Valve(s). 151 Dispenser Containment Float(s)and Chain(s). 151 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05-06 Dispenser 1% 07-08 ❑ Dispenser Containment Sensor(s). Model: ❑ Model: ill Shear Valve(s). a Shear Valve(s). 9 Dispenser Containment Float(s)and Chain(s). a Dispenser Containment Float(s)and Chain(s). Dispenser tut Dispenser ID! ❑ Dispenser Containment Sensor(s). Model: ❑ Dispotiser Containment Sensor(s). Model: D Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispanscr Containmont Float(s)and Chain(s). "If the facility contains mora tanks or dispensers,copy this form.include information for every tank and dispenser at the facility C.Certification- T certify that the equipment identified in this dteument was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e g.m000factures'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,t have also attached a copy of the; (theca ort that tepply): 13 System set-up Q Alarm history report Technician Name(print):Steve Parmenter Signature: . '. Mfg.Cert.#.: A28780 1CC# 5311561-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (488)971.2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 95112 Date of Testing/Servicing: 2/23/12