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9 0 Monitoring System Equipment Certirica�PEIVEU For Use By All Jurisdictions Within The State of California A uthoriry Cited- Chapter 617, Health and &4fety Code; Chapter 16, Division 3, Title 23, California Code qflfegga AMA 2015 This form must be used to document testing and servicing of monitoring equipment. A separate c� rtjficatiRK-V-M-"ENTAL. prepared for each rrionit9ring.5jXstem control panel by the technician who performs the work. A copy of this fdfWffiT9 ft9=VMWC%1T 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: 36 N. Cherokee Ln. City: Lodi, CA Zip: 95240 Facility Contact Person: Mana er Contact Phone No.: (209) 369-1525 MakelModel of Monitoring System: Gil EMC Date of Testing/Servicing. 1/28/15 B. Inventory of Equipment Tested/Certified Check the appropriate hoses to indicate specific equipment inspected/serviced: Tank IQ: 01"Regu Tank IQ- 02 -Prom ❑ In - Tank Gauging Probe. Model: VR 847390-107 0 In - Tank Gauging Probe. Model: VR 847390-107 Annular Space or Vault Sensor. Model- VR 794390,420 M Annular Space or Vault Sensor. Model: VR 794390420 Piping Sump \ Trench Sensor (s). Model: VR 794380-208 0 Piping Sump \ Trench Sensor (s). Model: VR 794390-205 0 Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s), Model: M Mechanical ]-me Leak Detector. Model: RJ 116.056-5 Mechanical Line Leak Detector, Model: ...vaporiess L02000 [) Electronic Line Leak Detector. Model: C] Electronic Line Leak Detector. Model: 0 Tank Overfill\ I ligh-Level Sensor, Model: 0 Tank Overfill % High -Level Sensor. Model: 0 Other ( specify equipment type and model in Section L on Page 2), [3 Other ( specify equipment type and model in Section E on Page 2), Tank IQ.• 03 -Diesel Tank ID! 11 In,'Tank Gauging Probe, Muriel: IR 1117390,107 0 In - Tank Gauging Probe. Model M Annular Space or Vault Sensor, Model: VR 794390420 C) Annular Space or Vault Sens.,, Model: M Piping Sump \ Trench Sensor (s). Model: VR 794380-208 0 Piping Sump \ Trench Sensor (s). Model: [) Fill Sump Sensor (s), Model: [) Fill Sump Sensor (s), Model: fl Mechanical Line Leak Detector, ModeI:__.Ka22�!e!$ LD2000 C] Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector, Model: p Electronic Line Leak Detector. Model: o Tank Overfill \ High -Level Sensor, Model: ❑ Tank Overfill \ High -Level Sensor. Model: 0 Other ( specify equipment type and model in Section E on Page 2), [1 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), Shear Valve (s). Dispenser Containment Float (s) and Chain (s), Dispenser Containment Float (s) and Chain (s), Dispenser IQ: 05.06 Dispenser ID. 07,08 n Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s), Model: 0 Shear Valve (s), Shear Valve (s). H Dispenser Containment Float (s) and Chain (s), 1 Dispenser Containment Float (s) and Chain (s). Dispenser ID: Dispenser I , I 0 Dispenser Containment Sensor (s). Model: n Dispenser Containment Sensor (s). Model: 0 Shear Valve (s). Q Shear Valve (s). –[I Dispenser Containment Float (s) and Chain (s). 0 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 0 Alarm history report Technician Name (print): Randy Wilkerson Signature- il-1101— Mfg. Cert.#,. A32404 — ICC# 5258560 -UT License. No.: 485184 Testing Company Name: Service Station Systems Phone No.: (4 8) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 1/28/16