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MONIT see G� he SYSTEeurisdictions MtCEtRTIO TION Authority Cited:Chapter 6.7, of Calif0in"M and Safety Code;Chapter 16,Division 3 Title 23, CWTOmia 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 o report must be oreoaretl far each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system mnerloperator. 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 CA Zip:95376 Facility Name: ULTRAMAR 3698(VALERO) City: TRACY Site Address: 153E 11TH ST Contact Phone No: 832-8815 QC-D-3 Date of Testing/Service: 02/09/2010 Facility Contact Person: MGR-CHELA Make/Model of Monitoring System:GILBARCO EMC Work Order Number. 2272103 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 87SY Tank ID: 87M X In-Tank Gauging Probe. Model. MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Madel: 794390-420 Annular Space or Vault Sensor. Model: 794390-02- X Piping SumprTrench Sensor(s). Model: 794380-208 Piping Sump/Trench Sensor(s). Madel: 794380-208 Fill Sump Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: 794380-208 X FX1V Mechanical Line Leak Detector. Model: X Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model. ATC' Tank Overfill/High-Level Sensor. Model: ATG 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 . Tank lD: In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 794390-420 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 794380-208 Piping SumpfTrench Sensor(s). Model: X Fill Sump Sensogs). 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: Electronic Line Leak Detector. Model: 71 Tank Overfill/High-Level Sensor. Model: ATG 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). Ispenser 1/2 Dispenser ID: 3/4 Dispenser Containment Sensor(s) Model: Dispenser Containment Sensors) Model: X❑Shear Valve(s). X Shear Valve(s) QX Dispenser Containment Float(s)and Chain(s). X Dispenser Containment Float(s)and Chain(s). Dispenser Or 5/6 Dispenser ID: F-1DispenserContainment Sensoria) Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear X Dispenser containment Floats)and Chain(s). Dispensserer containment tainment Floats)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). 10 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): ❑X System set-upX❑Alarm history report Technician Name(print): BRYAN KEYS Signature: Certification No.: B33515 License.No.: 743160(Class'A'General Enginerina Contractor License) Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 11000 N.MoPac Expressway,suite 500,Austin,TX 78759 Date of Testing/Servicing: 02/09/2010 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/08