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WK.W.I 'iii T I Monitoring System Equipment 'Coeri�7 i 'n" -- For Use By All Jurisdictions Within The State of California F _B 0 7 '118 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 cern€ca*�tFg,t�tnc ->taii t° HEALTH prepared for each monitoring system control panel by the technician who performs the work. A copy of this f4r�rmtt&i �i i d 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: 1124118 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced- Tank ID• 01 -Rego Tank ID• 02 -Prem ❑ In - Tank Gauging Probe. Model: VR 847390-107 ❑ In - Tank Gauging Probe. Model: VR 847390-107 ® Annular Space or Vault Sensor. Model: VR 794390.420 ® Annular Space or Vault Sensor. Model:VR 794390-420 Piping Sump \ Trench Sensor (s). Model: VR 794380.208 ® Piping Sump \ Trench Sensor (s). Model: VR 794390-205 Q Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ® Mechanical Line Leak Detector. Model: RJ 119.069.5 ® Mechanical Line Leak Detector. Model: Vapodess LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ 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 ID- 03 -Diesel Tank ID ❑ In - Tank Gauging Probe. Model: VR 847390-107 ❑ In - Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 794390.420 ❑ Annular Space or Vault Sensor. Model: (gl Piping Sump \ Trench Sensor (s). Model: VR 794380-20 ❑ Piping Sump 1 Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ® Mechanical Line Leak Detector. Model: yaporiess LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ 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). Dispenser ID. 01-02 Dispenser I - 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• 05-06 Dispenser ID• 0748 ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: ® Shear Valve (s). Do Shear Valve (s). ® Dispenser Containment Float (s) and Chain (s). oll Dispenser Containment Float (s) and Chain (s). Dispenser ID• Dispenser ID• ❑ Dispenser Containment Sensor (s). Model: I ❑ 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). *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 thatapply): ® System set-up ® Alarm history report Technician Name (print): Myke Briggs Signature:" Mfg. Cert.#.: B38235 ICC# 8033115 -UT License. No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 96112 Date of Testing/Servicing: 1/24/18