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0- Monitoring • • • - For Use By All Jurisdictions Within The State of California Authority Cited: Chapter S, 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 separate certification or report must bg prepared f r egch Monitorings stent ntr the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The o / r t s form to the local agency regulating UST system within 30 days of test date. A. General Information Facility Name: USA/Tesoro MAR 2 12013 Bldg. No. Site Address: 401 W. Kettleman Ln. City: Lodi, CA Zip: 95240 EN Facility Contact Person: Manager AI Contact Phone No,: (209) 368-8787 Make/Model of Monitoring System: Gil EMC , Date of Testing/Servicing: 2121113 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID• 01-Regu Tank ID: 02 -Prem ® In - Tank Gauging Probe. Model: VR 647390-107 11 In - Tank Gauging Probe. Model: VR 847390-107 N Annular Space or Vault Sensor. Model: VR 794390.420 ® Annular Space or Vault Sensor. Model: VR 794390-420 Piping Sump \ Trench Sensor (s). Model: VR 794390.208 Piping Sump 1 Trench Sensor (s). Model: Vit 794380-208 ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: 1� Mechanical Line Leak Detector. Model: RJ 116-056.6 Mechanical Line Leak Detector. Model: RJ 116-056-5 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ 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 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: ❑ 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 -Level Sensor. Model: ❑ 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). Dispenser ID:_0'1-02 Dispenser ED, ❑ Dispenser Containment Sensor (s). Model p 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; 05-06 Dispenser ID. 07-08 ❑ Dispenser Containment Sensor (s). Model: p Dispenser Containment Sensor (s). Model: ® Shear Valve (s). Shear Valve (s). Dispenser Containment Float (s) and Chain (s). Qjf Dispenser Containment Float (s) and Chain (s): Dispenser ID: Dispenser I ❑ 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). *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; (cheeks// that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): Myke Briggs Signature:" — Mfg. Cert.#.: ICC# 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: 2121113