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MONI'I ING SYSTEM CERTIFI&TION 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. separate certification or report- must be prdodfe4 fo .ach monitoring system control panel by the technician who performs the work. A copy of this form must be protrtiled;'to;;ttte,tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within -16V days of test "6*-, A. General Information Facility Name: VALERO Site Address: 1612 W Hammer Ln Facility Contact Person: Dinh Make/Model of Monitoring System: EMC B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Bldg. No.: City: Stockton Zip: 95209 _ Contact Phone No.: (209) 952-2903 Date of Testing/Servicing: 7/31/2007 Tank ID: T-1 87 Tank ID: T-2 91 ® Lo -Tank Gauging Probe. Model: PA0266096020 ® Ln -Tank Gauging Probe. Model: PA0265096M ® Annular Space or Vault Sensor. Model: PA02591144000 ❑ Annular Space or Vauh Sensor. Model: ® Piping Sump / Trench Sensors} Model: PA02692000010 ® Piping Sump / Trench Sensor(s} Model: PA02692000010 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD -2000 ® Mechanical Lane Leak Detector. Model: LD -2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Lane 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: T-3 Diesel Tank ID: ® In -Tank Gauging Probe. Model: PA0265096020 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: PA02691141000 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: PA02592000010 ❑ Piping Sump / Trench Sensor(.). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD -2000 ❑ Mechanical Line Ixak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Lane Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tack Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (speedy equtprnent type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 3/4 ❑ Dispenser Containment Sensor(s} Model: ❑ Dispenser Containment Sensors} Model: ® Shear Valve(s). ® Shea Valw(s)_ ® Dispenser Containment Float(s) and Chains} ® Dispenser Containment Float(.) and Chain(.). Dispenser ID: 5/6 Dispenser ID: 7/8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Smsat(s). Model: ® Shear Valve(s). ® Shear Valve(sy ® Dispenser Containment Float(s) and Cham(s). ® Dispenser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensors). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ 134enser Containment Float(s) and Chain(s). it ene iacniiy comams more tangs 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 manufacturers' guidelines. Attached to this Certification is information (e g. manufacturers' 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 report; (check all that apply): System set -u ® Alarm history report Technician Name Gavin Williams Signature: Certification No.: WIKT2074 License. No.: 05857 Testing Company Name: HMC- Henderson Maint Co Phone No.: (209) 467-7573 Site Address: PO Box 31325, Stoickton, CA 95213 Date of Testing/Servicing: 7/31/2007 Page 1 of 3