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i ri ii l Y 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 seoar ger ltfication ar�gort must be prepared for each monitgring gy�jpm 2oniml nand 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:'Shell/Tesoro I Bldg, No.: Site Address: 35 N. Cherokee Ln. City: Lodi, CA Zip: 95240 Facility Contact Person: Manager Contact Phone No.: 3209) 369-1525 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 6119/13 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 01-Regu Tank ID• 02 -Prem ❑ In - Tank Gauging Probe. Model: VR 847390.107 ❑ In - Tank Gauging Probe. Model: VR 847390-107 ❑ Annular Space or Vault Sensor. Model: VR 794390-420 ❑ Annular Space or Vault Sensor. Model: VR 794390420 ❑ Piping Sump \ Trench Sensor (s). Model: VR 794380.208 ❑ Piping Sump \ Trench Sensor (s). Model: VR 794390.205 ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Models ❑ Mechanical Line Leak Detector, Model: Rd 116-056-5 ❑ Mechanical Line Leak Detector. Model-yaeoriess LD2000 ❑ 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). Tank ID: 03 -Diesel Tank ID• ❑ In - Tank Gauging Probe. Model: VR 847390-107 ❑ In - Tank Gauging Probe, Model: N Annular Space or Vault Sensor. Model: VR 794390420 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump \ Trench Sensor (s). Model: VR 794380-206 ❑ Piping Sump \ Trench Sensor (s). Model: I] Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector, Model: yaporless LD2000 ❑ 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 D3-04 ❑ 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: 05-06 Dispenser ID 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 repasts, l have also attached a copy of the; (check all thatapply): System set-up ® Alarm history report Technician Name (print): Kris Bell Signature. Mfg. Cert.#.: B33709 ICC# 5297793 -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: 6/19/13