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FE8-18-2010 10:16 Service Station Systems 408 938 8888 P.03 ii sem Equipment"'Erfification 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. AA separate cettiiictltion_or re ort_ must be ploared for each monitoring sv.-,- control�anel 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: USA/Tesoro Bldg. No.: Site Address: 35 N. Cherokee Ln. Citv: Lodi, CA Zip: 95240 Facility Contact Person' Manager Contact Phone No.: (209) 368-1525 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 1/20/10 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank iD• 01-Rego Tank ID! 02-Plus 13 In - Tank Gauging Probe. Model: vR 847390-t97 ❑ In - Tank Gauging Probe, Model:vR $q73�-to7 IE Annular Space or Vault Sensor, Madel; VR 764399.x29 LIS Annular Space or Vault Sensor. Model; VR BaC� (3 Piping Sump \ Ttvneh Sensor (s). Model; vR 7943130-206 (3 Piping Sump \ Trench Sensor (s). Model: VR 794390-2o6 ® Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model; tj Mechanical Lino Leak Detector. Model; R9116-05" IN Mechanical Linc Leak Ntector. Model: RJ 978956 5 ❑ Electronic Line Leak Detector. Model; ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High-Level Sensor. Model; p Tank Overfill \ 1-ligh-Level SCnsor. Model: ❑ Other ( specify equipment type and model in Seodon E on Page 2). p Other ( specify equipmcnt type and model in Section F on Page 2). Tank lED• ®3-Prem Tank iia• C] In - Tank Gauging Probe. Model: VR 9473-197 ❑ In -Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: VR 794390-iB9 ❑ Annular Space or vault Sensor. Model: B Piping Sump \ Trench Sensor (s)• Model; vR 7143'" ❑ Piping Sump \ Trench Sensor (s), ❑ Fill Swap Sensor (s). Model; p Fill Sump Sensor (s). Model: lS Mechanical Line Leak Dctoctor. Model: RJ 119.0566 ❑ Mechanical Line Lank Detector. Model: ❑ Electronic Lino Leak Detector. Model; ❑ Electronic Line Link Detector. Model: ❑ Tank OverflI \ High-Level Sensor. Model; p Tank Overfill \high-Level Sensor. Model: C3 Other ( specify equipment type and model in Section F on Page 2). ❑ tither ( specify equipment typo and model in Section E on Page 2). Dispenser ID• 47'02 IDpenser iD' 03.04 E) Dispenser Containment Sensor (s). Model:Dispenser Containment Sensor (s). Model: IX Shear Valve (s). INShear Valve (s). IN Dispenser Containment Float (s) and Chain (s),Dispenser Containment Float (s) mid Chain (s). Dispenser YD• spenser ID•07-08 p Dispenser ContainmentSensor (s). Madel:Dispenser Containment Sensor (s}. Model: Ia Shear Valve (s).Sher Valve (s). IN Dispenser Containment Float (s) and Chain (s).Dispenser Containment Float (s) and Chain (S). Dispenser YD• 09'70 Dispenser SID° E3 Dispenser Containment Sensor (s). Ntodcl: _ ❑ Dispenser Containment Sensor (s). Model: a Shear Valve (s). ❑ Shear Valve (s). f3 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 iiia 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 equipmcnt. For any equipment capable of generating such reports, I have also attached a copy of the; (cheGt alt drat oPpI,V): ❑ System set-up ❑ Alarm history report Technician Name (print): Rand Wilkerson Signature: Mfg, Cert.#.: A32404 ICC# 5258560-UT License, No.: 485184 2445 971 408) - Testing Company Name: Sam. Sta, Sys. Phone No.; (- Testing Company Address: 680 Quinn Ave., San Jose, CA 96112 Date of Testing/Servicing: 1/20110