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09/22/2010 10:28 209-465-4988 HMC HENDERSON MAINT PAGE 06/11 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Calybrida 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 orreport 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 tlreJank 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) 838-7674 Make/Model of Monitoring System: GILBARCO EMC Date of Testing/Servicing: 6/22/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates eeiflee ui ment inspected/serviced: Tank ID; 87 Tank ID: 91 ®In-Tank Gauging Probe. Model: MAC•l ®in-Tank Gauging Probe. Model: MAG-1 ®Annular Space or Vault Sensor. Model: 420 ®Annular Space or Vault Sensor. Model: 420 ®Piping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensoria). Model: ®Mechanical Line Leak Detector. Model: LD2000 ®Mechanical Line Leak Detector. Model: FX1 V ❑Electronic Line Leak Detector. Model: ❑Electronic Line teak 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: DSL Tank ID: ®In-Tank Gauging Probe. Model: MAG-1 ❑In-Tank Gauging Probe. Model: •Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ID Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Season(s)- Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: FX1V ❑Mechanical Line Leak Detector. Model' ❑Electronic Cine 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 TD: 1-2 Dispenser ID: 3-4 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ®Shear Valve(s). 0 Shear Valve(s). J@ Dispenser Containment Float(s)and Chain(s). Z 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 Cham(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/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 capable of generating such reports,I have also attached a copy of the report;(check all that apply): ❑System set-up R Alarm ' ltfry report Technician Name(print): HEATH MCEVER Signature: 40e �— Certification No.: A27562 License.No.: 5236756-UT Testing Company Name: SST-SERVICE STATION TESTING Phone No.:(209) 465-5577 Testing Company Address: PO BOX 31465 STOCKTON CA 95213 Date of Testing/Servicing: 6/2212010 Page 1 of 3 Rev(2/08)