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ONIT#�G SYSTEM CERTIFI TION All Jurisdictions Within the State of Cal#brr Authority Cited. Chapter 6.7, d Safety Code, Chapter 16, Division 3 Title 23, Wornia 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 installed at the facility, 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 systems within 30 days of test date. A. General Information Facility Name: PARKWOOD VALERO Site Address: 1612 W. HAMMER LANE Facility Contact Person: KIU Make/Model of Monitoring System: EMC B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced City: STOCKTON CA Contact Phone No: 952-3370 Date of Testing/Service: 07/22/2004 Work Order Number: 2231643 Zip: 95209 TanklD: 1 TanklD: 2 X in -Tank Gauging Probe. Model: MAG X In -Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model: 420 X Piping Sumplfrench Sensor(s} Model: 208 PipingSump/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: LLD Mechanical Line Leak Detector. Model: LLD 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). TanklD: 3 TankID: X In -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model: X Piping Sumprrrench Sensor(s). Model: 208 Piping Sumpffrench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: LLD 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 : 1/2 Dispenser ID: 3/4 ❑ Dispenser Containment Sensor(s) Model: 7 Dispenser Containment Sensor(s) Model: X J Shear Valve(s). -X-1 Shear Valve(s) ❑ Dispenser Containment Float(s) and Chain(s). -X-1 Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: X❑ Shear Valve(s). Shear Valve(s). X 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 manufacturers' 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 set-up ® Alarm history report Technician Name (print): RHOME DESBIENS Certification No.: 3083 Signature: License. No.: Testing Company Name:Tanknology Phone No.: (800) 800-4633 Site Address: 8900 Shoal Creek, Bldg. 200 Austin, TX 78757 Date of Testing/Servicing: 07/22/2004 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01