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Monitoring eCertification 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 separate certification or report must be prepared for each monilor ng 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 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: 11/29112 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 01 -Rego Tank ID.: 02 -Preen ❑ In - Tank Gauging Probe. Model:VR847390-107 in- Tank Gauging Probe. Model: VR 847390.107 ❑ Annular Space or Vault Sensor, Model: VR 794390.420 ❑ Annular Space or Vault Sensor. Model: VR794390-420 ❑ Piping Sump \ Trench Sensor (s): Model; vR 794380-206 ❑ Piping Sump \ Trench Sensor (s), Model: VR 794390.205 ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: p Mechanical Line Leak Detector. Model: RJ 119.056.5 ❑ Mechanical Line Leak Detector. Model: Vaportess LD2000 ❑ Electronic Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: p 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 Ill• 03 -Diesel Tank IDo ❑ In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Model: VR U7390-907 ❑ Annular Space or Vault Sensor. Model: VR 794390.420 Q Annular Space or Vault Sensor. Model: ❑ Piping Sump \ Trench Sensor (s). Model: VR 794380-208 ❑ Piping Sump \Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: p fill Sump Sensor (s). Model: 1g Mechanical Line Leak Detector. Model: Vaporless L02000 p Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model p 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• 03.04 Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: ❑ Shear Valve (s). p Shear Valve (s). p Dispenser ContainmentFloat (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: O5-06 ❑ Dispenser Containment Sensor (s). Model: Dispenser ID,• 07.08 ❑ 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• p Dispenser Containment Sensor (s). Model: Dispenser ID ❑ Dispenser Containment Sensor (s). Model: p Shear Valve (s), p 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 reports, I have also attached a copy of the: (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): Randy Wilkerson Signature: i.1140L Mfg. Cert.#.: A32404 ICG# 5258560 -UT License. No.: 485184 Testing Company Name: Service Station Systems PhoneMwAftm fix I lam o. om IR Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Da o 9"M CE