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Monitoring System Equipment CertificafiTnCEIVED For Use ByA 71 Jurisdictions Within The State of California MAYI "'' ?V8 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 rep&WtjA�MENTAL E i_� pared for each monitoring system control panel by the technician who performs the work. A copy of this fo"-Asflo_Y�o`vPldjVTNIENT 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:Shell/Tesoro Bldg.No.: Site Address: 2706 Country Club Blvd. City: Stockton,CA Zip: 95204 Facility Contact Person: anager Contact Phone No.: (209)465-4756 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 517/18 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank IQ:01-Regu Tank IDrem 2 L�-P -—_ [I In-Tank Gauging Probe. Model: VR 84739Ci-107 El In-Tank Gauging Probe. Model: VR 847390.107 R Annular Space or Vault Sensor, Model: VR794390-420 M Annular Space or Vault Sensor. Model: VR794390-420 jg- Piping SumpN Trench Sensor(s). Model: VR 794380-20b D9 Ftping Sump\Trench Sensor(s). Model: VR 794380-208 Fill Sump Sensor(s). Model: VR 794380-208 01 Fill Sump Sensor(s). Model: VR 794380-208 Mechanical Line Leak Detector. Model: RJ 119-066-5 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). (3 Other(specify equipment type and model in Section E on Page 2). Tank 10: 03-Diesel Tank ID: [I In-Tank Gauging Probe. Model: VR 847380-107 [I In-Tank Gauging Probe. Model: Do Annular Space or Vault Sensor. Model: VR 754390-420 [3 Annular Space or Vault Sensor. Model: N Piping Sump N Trench Sensor(s). Model: VR 794380-208 [1 Piping Sump\Trench Sensor(s), Model: N Fill Sump Sensor(s). Model: VR 794380-208 ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: Vaporiess LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 0 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: VR 794380-208 R Dispenser Containment Sensor(s). Model: VR 794380-208 Shear Valve(s). 01 Shear Valve(s), ❑ Dispenser Containment Float(s)and Chain(s). [] Dispenser Containment Float(s)and Chain(s). Dispenser ID; 05-06 Dispenser ID.LF-08— sp s r". Dispenser Containment Sensor(s). Model: VR 794380-208 Dispenser Containment Sensor(s). Model: VR 794380-208 , 7,V 9h Valve(s). Shear Valve(s). 0 . .�pe �v D n "Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser Ill: 09-10 Dispenser 1%. I@ Dispenser Containment Sensor(s). Model: VR 794380-208 ❑ Dispenser Containment Sensor(s). Model: 00 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 inspectediserviced 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); 09 System set-up N Alarm history report Technician Name(print): Kris Bell , Signature: Mfg.Cert.#,: B33709 icc# 6297793-UT License.No.: 486184 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: 5/7/18