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Monitonirl System Equipment Pertification 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 to the tank system owner/operator within 30 days of test date. A. General information Em A separate certification or deport mustbe e work. A copy of this form must be provided rm to the local agency regulating UST system Facility Name: Shell/Tesoro _ SANJOAl ilNi'MM Bldg. No.: Site Address: 35 N. Cherokee Ln. L ENVIRONMENTAL ®T„ r,r,,,City: Lodi, CA rr5i �. Zip: 95240 Facility Contact Person: Manager Contact Phone No.: (209) 369-1525 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 1/28113 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 0i-Regu Tank I:D• Q2 -Prem ❑ In - Tank Gauging Probe. g g Model: VR 847390.107 ❑ In - Tank Gauging Probe, Model VR 847390.107 ! Annular Space or Vault Sensor. Model: VR 794390 -azo 0 Annular Space or Vault Sensor. Model: VR 794390.420 10 Piping Sump \ Trench Sensor (s). Model: VR 794380-208 0 Piping Sump \ Trench Sensor (s). Model: VR 794380-205 ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: Ip Mechanical Line Leak Detector, Model: RJ 116-056-5 ® Mechanical Line Leak Detector. Model: Va orless LD2000 ❑ Electronic Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Levet 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-Cliesel Tank ID• ❑ In - Tank Gauging Probe. Model: VR 847390.107 ❑ In - Tank Gauging Probe. — Model: 0 Annular Space or Vault Sensor. Model: VR 794390 420 ❑ Annular Space or Vault Sensor. Model: N Piping Sump \ Trench Sensor (s). Model: VR 794380.208 ❑ Piping Sump \ Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: I$ Mechanical Line Leak Detector. Model: Ve artess LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: p 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 I - 01-02 Dispenser ID 03'04 ❑ Dispenser Containment Sensor (s),. Model: ❑ Dispenser Containment Sensor (s). Model: 19 Shear Valve (s). N Shear Valve (s). IN Dispenser Containment Float (s) and Chain (s), 11 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: N Shear Valve (s). 12 Shear Valve (s). IN Dispenser Containment Float (s) and Chain (s). IS 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/seryiced 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 reports, I have also attached a copy of the; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): Myke Briggs Signature: 441 Mfg. Cert.#.: 638235 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: 1128113