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Y MONITORING SYSTEM CERTIFICATION op rUse By All Jurisdictions Within the State of Calif Authority Cited:Chapter 6. alth and Safety Code;Chapter 16, Division 3 Title alifomia 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 at the facility,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 sys em owner opera or. a owner opera r mus su in a copy o Isor m o e local agency regulating UST systems within 30 tlays of test dale. A.General Information Facility Name: ULTRAMAR 698 City: TRACY CA Zip:95376 Site Address: 153 E 11TH ST Contact Phone No:832-8815 Date of Testing/Service: 02/06/2003 Facility Contact Person: MGR-CHELA Make/Model of Monitoring System: GIL13ARCO EMS Work Order Number: 2225329 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 1 Tank ID: 2 In-Tank Gauging Probe. Model: MAG1/259999 In-Tank Gauging Probe. Model: MAGI/258267 19 Annular Space or Vault Sensor. Model: 420/SINGLE FLOAT X Annular Space or Vault Sensor. Model: 420/SINGLE FLOAT 71 Piping Sump/Trench Sensor(s). Model: 208/SINGLE FLOAT X Piping Sump/Trench Sensor(s). Model: 208/SINGLE FLOAT Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: X Mechanical Line Leak Detector. Model: FX1 V21200-3502 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 E on page 2). Other(specify equipment type and model in Section E on page 2). an an In-Tank Gauging Probe. Model: MAG1/221528 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: 71 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 E on page 2). Other(specify equipment type and model in Section E on page 2). spenser ❑ 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). Ispenser Ispenser 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 Floats)and Chain(s). Dispenser ID: 5/6 Dispenser lD: 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 Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the(Check all that apply): System set-up report; ❑ Alarm history report PRINTED NAME: STEVEN R.COLBY SIGNATURE: (F COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01