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MONITORING SYSTEM CERTIFICATION Use By All Jurisdictions Within the State of Calitbift Authority Cited:Chapter 6.7,W1th and Safety Code;Chapter 16, Division 3 Title 23wlifornia 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 system owner operator. I he owner operator must SUDMR a copy o is orm to t e local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: ULTRAMAR 698(VALERO) City: TRACY CA Zip:95376 Site Address: 153E 11TH ST Contact Phone No: 832-8815 QC-D-3 Date of TestinglService: 02108/2005 Facility Contact Person: MGR-CHELA MakelModel of Monitoring System:TLS-350 Work Order Number: 2234398 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank 1D: 1-87 SLV Tank ID: 2-87 MSTR In-Tank Gauging Probe. Model: MAG ® In-Tank Gauging Probe. Model: MAG -111 Annular Space or Vault Sensor. Model: 420 X Annular Space or Vault Sensor. Model: 420 Piping Sump/Trench Sensor(s), Model: 208 X piping SumplTrench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 X Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: X Mechanical Line Leak Detector. Model: FX1V 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). anK IU: 3-9 1 1 an In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 42U Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 208 Piping Sumplrrench Sensor(s), Model. Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank OverfilI/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). OtSpenser 10. rspenser 0 Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model- ®Shear Valve(s). Shear Valve(s) 71 Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ispensef IIJ. ® Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s), Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Floats)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Morsel: ❑ 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 ®Alarm history report Technician Name(print): DOUGLAS HARTY Signature: Certification No.: 006-05-0253 License. No.: Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8501 N. MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 02108/2005 Page 1 of 3 Based on CA form dated 03/01 Monitoring System Certification