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Monitoring System Equipment i 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 separate certification or report must be prepared for each monitoring system control panel 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:Mobil/Tesoro Bldg.No.: 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 Date of Testing/Servicing: 2/23118 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seryiced: Tank ID•01-Regu Tank ID• 02-Prem ❑ In-Tank Gauging Probe. Model: a®co PA2660960200 ❑ In-Tank Gauging Probe. Model: G®co PA2660960200 10 Annular Space or Vault Sensor. Model: VR 794390420 ® Annular Space or Vault Sensor. Model: VR 794390-460 11 Piping Sump 1 Trench Sensor(s). Model: VR 7$4380-209 ® Piping Sump\Trench Sensor(s). Model: VR 794390-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Vaporless LD2000 ® Mechanical Line Leak Detector. Model: Vaporless LD2000 Cl 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). p Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank IQ; ❑ 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 l 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.. 01-02 Dispenser ID. 03-04 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 11 Shear Valve(s). ® Shear Valve(s). al Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05-06 Dispenser I . 07-08 ❑ 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: ❑ 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; (check all thatapply): ® System set-up ® Alarm history report Technician Name(print): Randy Wilkerson Signature: LAY4 . Mfg.Cert.#.: A32404 ICC# 5258560-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: 2123118