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09/22/2010 10:28 209-465-4988 HMC HENDERSON MAINT PAGE 02/11 MONITORING SYSTEM CERTIFICATION 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 Code of Regulations 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 provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: TEXACO Bldg.No.: Site Address: 1405 CALIFORNIA City: ESCALON Zip: 95320 Facility Contact Person: CHOW Contact Phone No.: (209) 638-7674 Make/Model of Monitoring System: GILBARCO EMC Date of Testing/Servicing: 6/2212010 B. Inventory of Equipment Tested/Certified Check the aRprogriate boxes to indicate s cific a ui ment inspected/serviced: Tank ID: 87 Tank ID: 91 N In-Tank Gaugm,Probe. Model: MAGI 0 In-Tank Cmgmg Probe. Model: MAG-1 N Annular Space or vault Sensor. Model: 420 0 Anular Space or Vault Sensor. Model: 420 N Piping Sump/Trench Sensor(&). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 ❑Fill Sump Semor(s). Model: ❑Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: LD2000 0 Mechanical Line Leak Detector. Model: FXiV ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill t 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: DSL Tank ID: 0 In-Took Gauging Probe. Model: MAG-1 ❑Ic-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: N Piping Sump/Trench Semor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Seasor(s). Model: Q Fill Sump Sensor(s). Model: M Mechanical Line Leak Detector. Model: FX1 V ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector ModeL- .,❑Tank Overfill/High-Level Sensor. Model• ❑Tank Overfill t High-level Sensar. Model: ❑other(specify equipment type and model in Scction E on Pago 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3.4 ❑Dispeaser CoaMmmeat Seasor(sb Model: ❑DispenserContaimrent Samr(s). Model: N Shear Valve(s), N Shear Valve(s). 0 Dispenser Containment Metals)and Chain(s). 0 Dispenser Containmem Floats)and Cham(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Senser(s). Model: ❑Dispenser Contaimtent Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(&). ❑Dispenser Containment Floats)and Chain(s). EEIDispenser er ID: Dispenser ID: Containment Semots). Model: ❑Dispenser Containment Seasor(s). Model: Vaive(s). ❑Shear Valve(s). enser ConUinmem Floats)and Cham(s). ❑Dispenser Containment Floar(s)and Chain(s). *Ifthe 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 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 ca ble of generating such reports,I have also attached a copy of the report,,(check a0 that apply/: C3 system set-up ®Al history repo ` Technician Name(print): H TH MCEVE / ll Signanue: v CertificationNo.: A27662 15337fd3 License. o.: 5236756-UT Testing Company Name: SST-SERVICE STATION TESTING Phone No.:(209) 4655577 Testing Company Address: PO BOX 31465 STOCKTON CA 95213 Date of Testing/Servicing: 6/22/2010 Page 1 of 3