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MONITQWNG SYSTEM CERTIFICATION 1 Y' a By All Jurisdictions Within the State of Califomi Authority Cited:Chapter 6.7,H and Safety Code;Chapter 16,Division 3 Title 23, mia 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 oreoaretl for each monitorings tem 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 forth to the local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: ULTRAMAR 3698(VALERO) City: TRACY CA Zip:95376 Site Address: 153E 11TH ST Contact Phone No: 832-8815 QC-D-3 Date of Testing/Service: 02/10/2009 Facility Contact Person: MGR-CHELA Make/Model of Monitoring System:GILBARCO EMC Work Order Number: 2263498 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 87-1 Tank ID: 87-2 X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 724390-420 Annular Space or Vault Sensor. Model: 794390-420 X Piping Sump french Sensor(s). Model: 794380-208 Piping Sumpfrrench Sensor(s). Model: 794380-208 X Fill Sump Sensor(s). Model: 724380-208 )( Mechanical Line Leak Detector. Model: FX1 V Fill Sump Model: 794380-208 Mechanicall Line Leak ine k Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank OverfilUHigh-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Tank Overfill/High-Level Sensor. Model: Tank lD: Other(specify equipment type and rootlet in Section E on page 2). Tank lD: In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 794390-420 In-Tank Gauging Probe. Model' Annular Space or Vault Sensor. Model:X Piping Sump/Trench SenoModel: 794380-tog Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: FX1V Mechanical Line Leak Detector. Model: Electronic Line Leak Detector, Model: Tank Overfll/Hig[FLevel Sensor. Model: Electronic Line Leak Detector. Model: Other(specify equipment type and model in Section E on page 2). Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Ispenser 1/2 Dispenser ID: 3/4 Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: X❑Shear Valve(s). —Xj Shear Valve(s) QX Dispenser Containment Float(s)and Chain(s). X Dispenser Containment Float(s)and Chain(s). Dispenser lD: 5/6 Dispenser ID: Dispenser Containment Sensors) Model: Dispenser Containment Senors). Model: X❑ Shear Valve(s), Shear Valve(s). X Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensors) 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 WrlifiCation 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 0 Alarm history report/�/y '/y! Technician Name(print): BRYAN KEYS Signature: //*— / v ^— Certification No.: B33515 License.No.: 743160(Class'A'General Enginering Contractor License) Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8501 N.MoPac Expressway,suite 400,Austin TX 78759 Date of Testing/Servicing: 02/10/2009 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01