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Monitoring0 ! Equipment ! ! System on For Use By All Jurisdictions Within The State of Caliornia 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 report must be loured for each monitoringsystem 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 system within 30 days of test date. A. General Information Facility Name: 'Shell/Tesoro Bldg. No.: Site Address: 35 N. Cherokee Ln. City: Lodi, CA Zip: 95240 Facility Contact Person: Manager Contact Phone No.: (209) 369-1525 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 3/7/13 B. Inventory of Equipment Tested/Certified Check the-annronriate boxes to indicate specific equipment insnected/serviced: Tank IIS 01 -Rego Tank ilk: 02 -Prem ❑ In - Tank Gauging Probe, Model VR 847390-107 ❑ In - Tank Gauging Probe, Model: VR 847390-107 1Z Annular Space or Vault Sensor. Model: VR 794390-420 X Annular Space or Vault Sensor. Model: VR 794390-420 ❑ Piping Sump \ Trench Sensor (s). Model: VR 794380408 ❑ Piping Sump\ Trench Sensor (s). Model: VR 794390408 ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s), Model: ❑ Mechanical Line Leak Detector. Model: RJ 1165-066-5 ❑ Mechanical Line Leak Detector. Model: Vaeortess 1,02000 p Electronic Line Leak Detector. Model ❑ Electronic Line Leak Detector. Model: ❑ "rank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ Other ( specifye and model in Section E on Page 2). ment , p Tank ice• 03-D esel Tank ❑ In - Tank Gaugi ❑ In - Tank Gauging Probe. Model: VR 847390-107 ❑ Annular Space or Vault Sensor. Model: VR 794390.420 ❑ Annular Space or Vault Sensor, Model: ❑ Piping Sump \ Trench Sensor (s). Model: VR 784380-2ae ❑ Piping Sump\ Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). APR . Hd� l Z [3 Mechanical Line Leak Detector. Model: Vaeoriess LD2000 [3 Mechanical Line Leak Detector. Mode: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Det tar, nAgModel: ❑ Tank Overfill \ High -Level Sensor. Model; ❑ Tank Overfill \ High -Leve F' wEi _.____� Page 2). ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ Other ( specify equipment ty 1r" Dispenser ID• 03-04 t Eon 11ENT Dispenser ID- 01-02 ❑ 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 Floats) and Chain (s). Dispenser ID! 11 Dispenser ID• ❑ Dispenser Containment Sensor (s). Model: 11 ❑ 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 Piot 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 thatupply): ❑ System set-up ❑ Alarm history report Technician Name (print): Myke Briggs Signature:: ` Mfg. Cert.#.: B38235 ICC# 8033115•UT License. No.: 485184 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: 3/7/13