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FEB -14-2012 08:01 Service Station Systems 408 938 8888 P.03 MonitorftQ System t erticati For Use Sy All Jurisdictions Within The Stab of Cal fornia Authority Cited: Chanter 6.7, Health and .Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This forth must be used Co document Ceding and servicing of monitoring equipment, A-aoza 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 LIST 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 'Lip: 95240 Facility Contact Person: Manager Contact Phone: No.., (209) 369-1525 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 1118J12 S. inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Inmpectedlserviced: Tank I[Q:01-Regu _ Tank iD' 02 -Prem ❑ In - Tank Gauging Probe. Model: VR 947300-107 ❑ In - Tank Gauging Probe. Model: VR 847390.107 ® Annular Space or Vault Sensor. Model: VR 794300-420 a Annular Space or Vault Scnsor. Model: VR 794390.420 10 Piping Sump \ Trench Sensor (s). Model: VR 794380.208 ® Piping Sump \ Trench Senior (s). MndCt: VR 794390.205 Q Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (a), Model: Mechanical Linc Leak Detector. Model: RJ 11 6-056s tj Mechanical Line Leak Detector. Model: vaporless L02000 Q Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank 0-rerfill \ High -Level Sensor. Model: ❑ Tank Overfill \ Nigh -Level Scnsor, Model: ❑ Other ( specify equipment type and model in Section R on Page 2). ❑ Other ( spccity cquipment type and model in Section E on Page 2). Tank ill: 03 -Diesel Tank (D• p In - Tank Gauging Probe, Model: VR 847390-107 ❑ in -'rank Gauging Probe. Model: 8 Annular Space or Vault Sensor. Model: VR 794390420 ❑ Annular Space or Vault Scnsor, Modcl: 0 Piping Sump \ Trench Sensor (s). Model: VR 794390.209 ❑ Piping Sutnp \ Trench Sensor (s), Model: ❑ Fill Sump Scnsor (s). Model: ❑ Fill Sump Sensor (s). Model: ® Mechanical Linc Leak Derccror, Model: .yaportese L02000 (] Mechanical Lino Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Gi Electronic Line Leak Detector, Model; ❑ Tank Overfill \ fligh-Luvcl Sensor. Model: ❑ Tank Overfill \ High-I.,cvel Sensor, Model:_. ❑ Other ( specify equipment type and model in Section Eon Page 2). ❑ Othcr ( specify equiptnent typ0 and model in Section E on Page 2). Dispenser ID: 01.02 Dispenser ID.- 03-04 ❑ Dispenser Containment Sensor (s), Model; ❑ Dispenser Containment Scnsor (s). Model: ® Shear Valve (s). X Shear Valve (s). 11 Dispenser Containmcnt Float (s) and Chain (s). IS Dispenser C:ontainmcat Float (s) and Chain (s). Dispenser ID: 05-06 Dispenser ID: 07-08 ❑ Dispcnscr Con tai nmcnt Sensor (s). Model: ❑ ni,;penscr Cont tinmeat Scnsor (s). Model: to Shcar Vaivc (s). V Shear Valve (s). ig Dispenser Containment Float (s) and C'hain (5). 1I Dispenser Containmcnt Float (-,)and Chain (s), Dispenser iD- Dispenser iDo 0 Dispenser Containmcnt Scnsor (s), Model; (0 Uispcnscr Containmcnt Sensor (s). Modal: ❑ Shear Valve (s). ❑ Shear Valve (s). Dispenser Containment Float (s) and Chain (s), ❑ Dispenser Containmcnt 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 t0 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 that:pply): ❑ System set-up ❑ Alarm history report Technician Name (print): RXan Casey Signature: Mfg, Cert.ir.: B38961 1CC# 8057554 -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 t'csting/Servicing: 1/18/12