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Monitoring System Equipment Certification For use By All Jurisdictions Within The State of California Authority Cited: Chapter 6 7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A acpgrate certification or rep!2rt must be pr form must be provided S,2ared for each monitoring 5ystcm golml panel by the technician who performs the work. A copy of ibis 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. Nod Site Address: 401 W. Kettleman Ln. City-, Lodi, CA , Zip: 95240 Facility Contact Person: Manager Contact Phone No.: (209) 368-8787 Make/Model of Monitoring System: Gil EMC B. Inventory of Equipment Tested/Certified Date of Testing/Servicing: 2/18114 W 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 or the; (checkoff thstoppfy): [j System set-up Cl Alarm history report . . . Z_ . 7e04 Technician Name (print): Kris Bell Signature. Mfg. Cert,#.: B33709 — ICC# 5297793 -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: 2/18114 RMEW, ED Tank IQ: 01-R-gu Tank IQ! 02 -Prom J:) In - Tank Gauging Probe. Model: -VR 8473MI07 - 0 in - Tank Gauging Probe, Model: VR 847390-107 0 Annular Space or Vault Sensor, Model: VR 794390-420 0 Annular Space or Vault Sensor. Model: VR 794390420 Cg Piping Sump \ Trench Sensor (S). Model: VR 7$080-208 - M Piping Sump \ Trench Sensor (s). Model: VR 794380-208 C] Fill Sump Sensor (s). Model: 0 Fill Sump Sensor (s). Model: M Mechanical Line Leak Detector, Model: RJ 116-056-6 - M Mechanical Line Leak Detector. Model:EJ _1164M5 0 Electronic Line Leak Detector, Model: [] Electronic Line Leak Detector, Model: ❑ Tank Overfill \ High -Level Sensor, Model: 0 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 ID Tank IIS C] In - Tank Gauging Probe. Model: [3 In - Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump\ Trench Sensor (s). Model: 0 Piping Sump \ Trench Sensor (s), Model: [I Fill Sump Sensor (s). Model: [] Fill Sump Sensor (s). Model: [3 Mechanical Line Leak Detector. Model: [3 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High-Lcvel Sensor. Model: (3 Other ( specify equipment type and model in Section E on Page 2). [3 Other ( specify equipment type and model in Section E on Page 2), Dispenser I •. 01-02 Dispenser 1 03-04 0 Dispenser Containment Sensor (s). Model: 0 Dispenser Containment Sensor (s). Model: gj Shear Valve (s). 0 Shear Valve (s), IM Dispenser Containment Float (s) and Chain (s). 0 Dispenser Containment Float (s) and Chain (s). Dispenser 1D OS Dispenser ID; 07-08 ❑ Dispenser Containment Sensor (s), Model: ❑ Dispenser Containment Sensor (s). ModeL Shear Valve (s). Shear Valve (s). Ig Dispenser Containment Float (a) and Chain (s). jll Dispenser Containment Float (a) and Chain (s), Dispenser IQ_L_ 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). W 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 or the; (checkoff thstoppfy): [j System set-up Cl Alarm history report . . . Z_ . 7e04 Technician Name (print): Kris Bell Signature. Mfg. Cert,#.: B33709 — ICC# 5297793 -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: 2/18114 RMEW, ED