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04/19/2002 09:10 209,3653 TANKNOLOGY • PAGE 06 `j 7b1*Rx*1gy MONITORING SYSTEM CERTIFICATION For Use By AN Judsdfodons 1410fin the State of CaNfomis Authority Cited Chapter 6.7. Health and Safety Code; Chapter 16, Division 3 1 ife 23, Cafiromm Code of Regulations This form must be used to document testing and servicing of monitoring equipment, If more than one monitoring system control panel Is Installed of the facility,a"parole cadaicarion or much must be papered for each momlorine System control panel by the tachnlden who performs the work. A copy of this form must be provided to the lank system pwnedopemtor. The owner/opnrutnr rnusl xuhmit a copy of this form to the local agency regulating UST systems within 30 days of fear fete. A.General InfotTnation Facility Name; ULTRAMAR 698 City: TRACY CA Zip: 96376 Site Address: 153E 11TH ST Contact Phone No: 832.8815 Facility Contact Person: MGR-CHEU1 Date of Testing/Service: 03/20/2002 Make/Model of Monitoring System. GILBARCO EMC Work Order Number: 2221561 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inepected/serviced Tank ID: SUP Tank ID: REG 1 In-Tank Gauging Probe. Model. In-Tank Gauging Probe. Model: Annular Space or Vaua Sensor. Model'. - Annular Space or Vauk Sensor, Madel: Piping SumprTreneh Sonsor(s). Model: — — Piping Sum IVTronOh Scrawls). Model: Fill Sump Sensor(s). Model: _ Fill Sump Sensor(*). Model: Mechanical Line Leah Delectoi. Model', _ Mechanical Line Leak Detector. Model' Electronic Line Leak Dntectoi. Model: Electronic Line Leek Detector. Model: Tank Overfill/High-Level Sonsar. Model, EXTERNAL Tank Ovedlll/Hugh-Level Sensor. Model' EXTERNAL Other(specify equipment type awl model In Section E on page 2). Other(apecey equipment type and model In Section E on page 2). Tank 10: Tank ID: In-Tan%Gauging Probe. Model' _ In-Tank Gauging Probe. Model: Annular Space or Vaua Sensor Modal. Annular Space or Vault Sensm. Model' Piping SumprTmnch Sensor(s). Model; Piping SunlprTrehch Samaria). Model: Fill Sump Sensor(a). Model: - FIII Sump Sensor(.). Model: Mechanical Line Leak Detector Model: _ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model. Electronic Line Leak Detector. Model: X Tank Overnll/High-Lovel Sensor. Model: EXTERNAL Tank Overfill/Nigh-Level Sensor. Model: Other(specify equipment type and model in Sention E an page 2). Other(specify equipment type and model in Section E on page 2). IspenserDispenser Dispenser Conleinment Sensuns) Model — Dispenser Containment Senaor(s) Model: Shear Valve(*). Shear VaMe(s) Dispenser Containment Float(.)and Chalm(s). Dispenser Containment Float(a)and ChAh(e). Dispenser ID: Dispenser ID: Dispenser Containment Sansor(s) Model Dispenser Containment Sensor(e). Model: Shear Velvets). Shp.,Valve(s), Dispenser Containment Most(s)and Chan(s) 71 Dispenser Containment Float(*)and Chaln(s). Dispenser 10: Dispenser 10: Dispenser Containment Sensor(s) Model Dispenser Containment Smaor(s). Model: Shear Valve(*). Shear Velve(s). Dispenser Containment Floags)and Chain($). 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 Site Plan showing the layout of monitonng equipment.For any equipment capable of generating such reports,I have also attached a copy of the(Check all that apply; System sat-up report; Alarm history report PRINTED NAME MICHAEL T LEVESQUE SIGNATURE: y9for�a�t �� COMPANY: Tanknology PHONE NO; (800)800.4633 page 1 of 3 Based on CA form dated 03/01