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Monitoring System Equipment Certlification .For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 67, Health and Safety Code; Chapter / 6, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. AgMtecertification !2rreport must be dared for eafh monitoring, sys -a trol cQnpgngl by the technician who performs the work. A copy of this form must be provided J�L 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: 96240 Facility Contact Person: Manager Contact Phone No.: (209) 369-1525 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 1128/14 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment hispectedl.wry iced, Tank.111,• 01-Regu Tank IQ: 02 -Prom 0 In - Tank Gauging Probe. Model: VR 947390-107 13 In - Tank Gauging Probe. Model: VR 647390.I07 12 Annular Space or Vault Sensor. Model: VR 794390-420 M Annular Space or Vault Sensor. Model: VR 79430420 * Piping Sump \ Trench Sensor (s), Model: VR 794360.208 M Piping Sump N Trench Sensor (s). Model: VR 794390-206 * Fill Sump Sensor (s), Mode); [I Fill Sump Sensor (s). Model: 11 Mechanical Line Leak Detector. Model: RJ 116-a66-6 Qj Mechanical Line Leak Detector, Model: Vmrless 1.02000 ❑ Electronic Line Leak Detector, Model: 0 Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: C] Tank Overfill \ High -Level Sensor. Model: 0 Other ( specify equipment type and model in Section E on Page 2); p Other (specify equipment type and model in Section E on Page 2). Tank IQ; 03 -Dieser Tank IQ: [I In - Tank Gauging Probe, Model: VR 947390-101 - [3 In - Tank Gauging Probe. ModeL M Annular Space or Vault Sensor, Model: VR 79430420 - 0 Annular Space or Vault Sensor, Model: p§ Piping Sump \ Trench Sensor (s), Model: VR 794380-208 - 0 Piping Sump \ Trench Sensor (s). Model: Fill Sump Sensor (s). Model: 0 Fill Sump Sensor (s), Model: Mechanical Line Leak Detector. Model: Vaporiess 1.02000 [] Mechanical Line Leak Detector.. Model: C3 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill \ High -Level Sensor. Model: 0 Tank Overfill \ High -Level Sensor. Model: [I 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 IQ: 01-02 Dispenser IDz 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 ID. 06-06 Dispenser IQ: 07-08 [] Dispenser Containment Sensor (s). Model: [3 Dispenser Containment Sensor (s). Model: Cl Shear Valve (s). tM Shear Valve (s), Dispenser Containment float (s) and Chain (s). qp Dispenser Containment Float (s) and Chain (s). Dispenser ID Dispenser ID: 0 Dispenser Containment Sensor (s), Model: [] Dispenser Containment Sensor (s). Model: ❑ Shear Valve (s). C] 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 man ufacturer*s gu idellaim 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 aft IhAlappfy): [] System set-up 0 Alarm history report Technician Name (print): Kris Bell Signature: Mfg, Cert,#.: _1333709 iCC# 5297793 -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 Test'A 50MVt