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MONITORING SYSTEM CERTIFICATION RECEIVED For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California &AU jaggWons This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring_ system control panel by the technician who performs the work. A copy of this form must be P6kkVf i �Y�ALo��[gp[t�,tol. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of te6 da /. EPRTM ENT I I -j A. General Information U Facility Name: Valley Pacific Petroleum Site Address: 1524 Fresno Ave. Facility Contact Person: Mike Eliason Make/Model of Monitoring System: Gilbarco EMC B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: City Bldg. No.: N/A Stockton, CA Zip: 95206 Contact Phone No.: (209) 993-8793 Date of Testing/Servicing: 03109117 Tank ID: T-1 Diesel Wank Ill: ❑ In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model: VR -Mag -Plus ® Annular Space or Vault Sensor. Model: VR -420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: VR -208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD -2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: OPW Flapper Valve ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment t}pe and model in Section E on Page 2). 'tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model. ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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 I. on Page 2) ❑ Other (specify equipment type and model in Section F on Pace _2) Dispenser ID: #1-2 Dispenser ID: #1 Satellite ❑ Dispenser Containment Sensor(s). Model: Gilbarco-011 ❑ Dispenser Containment Sensor(s). Model: Gilbarco-011 ❑ Shear Valve(s) ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ID: #2 Satellite /#3 Satellite Dispenser ID: #3-4 ❑ Dispenser Containment Sensor(s). Model: Gilbarco-011 ❑ Dispenser Containment Sensor(s). Model: VR -208 ❑ 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). *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/seryiced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' 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 report; (check all that apply): ® System 4� set-up ® Alarm history report Technician Name (print): Richard Thomas Signature: Certification No.: 834022 License. No.: 803616 Testing Company Name: CGRS, Inc. Phone No.: 916-991-1100 Testing Company Address: 5444 Dry Creek Rd. Sacramento, CA 95838 Date of Testing/Servicing: 03109117 UN -036 — www.unidocs.org Rev. 01/17/08