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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the state of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. 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. 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 Facility Name: Lathrop Chevron Bldg. No.: Site Address: 140 Lathrop Rd. City: Lathrop Zip: 95330 Facility Contact Person: Owner -Jesse Contact Phone No.: (209) 982-5005 Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 12/16/2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviccd: Tank ID: #1 -Regular Tank ID: #2 -Supreme Z In -Tank Gauging Probe. Model: PA02650960100-87 Z In -Tank Gauging Probe. Model: PA02650960100-87 Z Annular Space or Vault Sensor. Model: PA02591144000 Z Annular Space or Vault Sensor. Model: PA02591144000 Z Piping Sump I Trench Sensor(s). Model: 794380-208 Z Piping Sump I Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: VMI LD2000 ® Mechanical Line Leak Detector. Model: VMI LD2000 ❑ 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}. Tank ID: #3 -Diesel Tank ID: # Z In -Tank Gauging Probe. Model: PA02650960100-87 ❑ In -Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: PA02591144000 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensar(s). Model: Z Mechanical Line Leak Detector. Model: VMI LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill I High -Level Sensor. Model: ❑ Other (spccify equipment type and model in Section F, (11, Page 2). ❑ Other (specify equipment type and model in Seelion E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: (� Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Float(s) and Chain(s). Z Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ® Shear Valve(s). Z Dispenser Containment Float(s) and Chain(s). Z Dispenser Containment Float(s) and Chain(s). nser ID: 9-10 Dispenser ID: 11-12 penserContainmentSensor(s). Model:❑Dispenser rD Containment Sensor(s). Model: earValve(s). Z Shear Valve(s). spenser Containment Float(s) and Chain(s). Z 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 Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (cheek all that apply): ❑ System set-up Z Alarm history report Technician Name (print): _Jeff Conger Signature: �~ Certification No.: A22219 License. No.: ICC# 1801782 UT CSLB# 894932 Testing Company Name: Pinnacle Fuel Compliance Services, Inc. Phone No.: (408) 206-9840 Testing Company Address: P.O. Box 32849 San Jose, CA 95152-2849 Date of Testing/Servicing: 12/16/2013 Page 1 of 3