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n f Monitoring System Equipment CertificatiO4EB 2 5 2016 For Use By All Jurisdictions Within The State of California Authority Cited.• Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, 77de 23, California CodfYMONMENTAL This form must be used to document testing and servicing of monitoring equipment. A separate certification or Ag RTVl=NT nreuared 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 UST system within 30 days of test date. A. General Information Facility Name: Shell/Tesoro Bldg. No Site Address: 35 N. Cherokee Ln. City; I..odI,;CA Zip: 95240 Facility Contact Person: Manager Contact Phone No.: (209) 369-1525 Make/Model of Monitoring System: Gil EMC B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 1 /26/16 Tank ID- 01-Regu Tank 1D: 02 -Prem ❑ In - Tank Gauging Probe. Model: VR9473904a7 ❑ In - Tank Gauging Probe. Model: vR 847320.1o7 ® Annular Space or Vault Sensor. Model: VR 794399420 0 Annular Space or Vault Sensor. Model: VR 784390.420 0 Piping Sump \ Trench Sensor (s). Model: VR 794380.208 ® Piping Sump \ Trench Sensor (s). Model: VR 7943.205 ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: 11 Mechanical Line Leak Detector. Model: RJ 119.088.8 Q1 Mechanical Line Leak Detector. Model:yaportess 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 947390.107 ❑ In - Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 794390420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump \ Trench Sensor (s). Model: VR 704300.208 ❑ Piping Sump \ Trench Sensor (s). Model: ❑ Fill Sump Sensor (s), Model: ❑ Fill Sump Sensor (s). Model: ® Mechanical Line Leak Detector. Model:_yaporless 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 ID• 03-04 ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: ® Shear Valve (s). W Shear Valve (s). N Dispenser Containment Float (s) and Chain (s). ® Dispenser Containment Float (s) and Chain (s). Dispenser ID, 05-00 Dispenser ID• 07-08 ❑ 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 ED: 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; (cheekafi thafappiy). ❑ Systemact-up ❑ Alarm history report Technician Name rmt): Myke Bel s �rw (p 99 Signature: I/ Mfg. Cert.#.: B38236 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 95112 Date of Testing/Servicing: 1/26116