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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Calofmia Authority Chapter 6.7, Health and Safety Code; Chapter 16, Division 23, California Code of Regulations This Form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is insalled at the facility, a separate certification or report must be prepared for each monitring 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 tot a local agency regulating UST systems within 30 days of test date. Instructions are printed on the back page. A. General Information Facility Name: ULTRAMAR 641 Site Address: 1210 E. HAMMER LANE @ WEST LANE Facilty Contact Person: MGR - VALERIE Make/Model of Monitoring System: GILB EMC B.Inventory of Equipment Tested/Certified Tank ID: 1 City: STOCKTON Contact Phone No: 477-3111 Date of Testing/Service: 07/10/2001 Word Order Number: 2217647 Check the appropriate boxes to Indicate specific equipment inspected/serviced In -Tank Gauging Probe. Model: 2651320200 Annular Space or Vault Sensor. Model: 2591144000 Piping Sump/Trench Sensor(s). Model: 2592000010 Fill Sump Sensor(s). Model: Model: Mechanical Line Leak Detector. Model: FX1 V Electronic Line Leak Detector. Model: Model: Tank Overfill/High-Level Sensor. Model: 61 SO Dispenser Containment Sensor(s) Model: Shear Valve(s). Dispenser Containment Float(s) and Chains(s). Other(specify equipment type and model in Section E on page 2). In -Tank Gauging Probe. Model: 2651320200 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 2592000010 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Dispenser Containment Float(s) and Chains(s). Other(specify equipment type and model in Section E on page 2). C. Certification CA Zip: 95210 Tank ID: 2 Model: KI In -Tank Gauging Probe. Model: 2651320200 Annular Space or Vault Sensor. Model: 2591144000 R, Piping Sump/Trench Sensor(s). Model: 2592000010 Fill Sump Sensor(s). Model: q Mechanical Line Leak Detector. Model: FX1 Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 61 SO Dispenser Containment Sensor(s) Model: X1 Shear Valve(s). RJ' Dispenser Containment Float(s) and Chains(s). -1 Other(specify equipment type and model in Section E on page 2). In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Dispenser Containment Float(s) and Chains(s). Other(specify equipment type and model in Section E on page 2). 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 manufacturers checklists) necessary to verify that this information is correct and a Site 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 that apply): System setup report,' ® Alarm history report PRINTED NAME: JEFF CONGER SIGNATURE: COMPANY: Tanknology PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 05/00