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P 100CEIVE Monitoring System Equipment Certificate, For Use By All Jurisdictions Within The State of Cal forma Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Codtff HEALTH This form must be used to document testing and servicing of monitoring equipment. A sMarate certification or raml CES prepared 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 mast submit a copy of this form to the local agency regulating UST system within 30 days of test date. A. General Information Facility Name: ShellITesoro Site Address: 13975 E. Hwy 88 City: Lockeford, CA Bldg. No.; Zip: 95237 Facility Contact Person: Manager Contact Phone No.: (209) 727-0823 Make/Model of Monitoring System: Gil EMC B. Inventory of Equipment Tested/Certified Dof T : 8/28118 rt.Pp,f IhP nnnrnnrintp hnYPC to indipnfe Qnpriflp equipment insnected/serviced: ate esting/Servicing *If the facility Contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility Tante ID• 01-Regu ® In - Tank Gauging Probe, Model: VR 646390-111 Annular Space or Vault Sensor. Model: VR 794380.301 ® Piping Sump \ Trench Sensor (s). Model: VR 867080411 ® Fill Sump Sensor (s). Model: VR 867080.111 ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector, Model: VR series 8484 ❑ Tank Overfill \ High -Level Sensor, Model: VR 790091-001 Other ( specify equipment type and model in Section E on Page 2). Tank ID• 02 -Prem ® In - Tank Gauging Probe. Model: VR 846390.111 Z Annular Space or Vault Sensor. Model: VR 794380401 ® Piping Sump \ Trench Sensor (s). Model: VR 867080*111 ® Fill Sump Sensor (s). Model: VR 867080-111 ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR Series 8484 ❑ Tank Overfill \ High -Level Sensor. Model: VR 790091.001 ® Other ( specify equipment type and model in Section E on Page 2). Tank ID• 03-1)iesel ® in - Tank Ganging Probe. Model: VR 846390.111 Tank FD ❑ In - Tank Gauging Probe. Model: ® ® Annular Space or Vault Sensor. Piping Sump \ Trench Sensor (s). Model: Model: VR 794380.301 VR 867080.111 ❑ ❑ Annular Space or Vault Sensor. Piping Sump \ Trench Sensor (s). Model: Model: 0 ❑ Fill Sump Sensor (s). Mechanical Line Leak Detector. Model: Model: VR 867080.111 ❑ ❑ Fill Sump Sensor (s). Mechanical Line Leak Detector. Model: Model: ❑ 19 Electronic Line Leak Detector. Tank Overfill \ High -Level Sensor. Other ( specify equipment type and model Model: VR Series 8484 Model:VR 780091-001 in Section E on Page 2). ❑ ❑ ❑ Electronic Line Leak Detector. Model: Tank Overfill \ High -Level Sensor. Model: Other( specify equipment type and model in Section E on Page 2), Dispenser ID• 01'02 ® Dispenser Containment Sensor (s). Model: VR 867080411 Dispenser ID• 03-04 ® Dispenser Containment Sensor (s). Model: VR 867080-111 ® Shear Valve (s). ® Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser IP: 0748 ® Dispenser Containment Sensor (s). Model: VR 8 670 80-111 Dispenser IDU 0"S ® Dispenser Containment Sensor (s). Model: VR 857080.111 ® Shear Valve (s). ® Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID• Dispenser ❑ ID• 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). 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 invert that this information is correct and a Plot Plan showing the layout of monitoring equipment. rm• any equipment capable of generating such reports, Y have also attached a copy of the; (check all thatappty): ® System set-up Technician Name (print�KriS Bell Mfg. Cert.#.: B33709 ICC# 8833000 DO Alarm history report License. No.: 485184 Testing Company Name: Service Station Systems Phone No.: 408) 971-2445 Testing Company Address: 680 Quinn Ave., 0an 1ose, CA 95112 Date of Testing/Servicing: 8128/18