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®Taaalc,*tology' MONITORING SYSTEM CERTIFICATION Use By All Jurisdictions Within the State of Califor Authority Cited:Chapter 6.7,ALralth and Safety Code;Chapter 16,Division 3 Title 2 , 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 mori tormg 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 ovmerioperator 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 492 City: MANTECA CA Zip:95336 Site Address: 470 N MAIN ST Contact Phone No:823-1344 Date of Testing/Service: 12/12/2002 Facility Contact Person: MANAGER Make/Model of Monitoring System: GBCO EMC Work Order Number. 2224699 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced M LEADED Tank ID: SUPREME auging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG pace or Vault Sensor. Model: GBCO 010 Annular Space or Vault Sensor. Model: GBCO 010 p/Trench Sensor(s). Model: GBCO 000 Piping Sumprrrench Sensor(s). Model: GBCO 000 Sensor(s). Model: Fill Sump Sensor(s). Model: l Line Leak Detector. Model: RJ FX1V Mechanical Line Leak Detector. Model: RJ 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(spedfy equipment type and model in Section E on page 2). Tank lD: TankID: In-Tank Gauging Probe. Model: to-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sumprrrench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 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 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). Dispenser : 1/2 Dispenser ID: 718 ❑Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: X❑Shear Valve(s). X ShearValve(s) ❑X Dispenser Containment Float(s)and Chain(s). X Dispenser Containment Float(s)and Chain(s). Dispenser ID: 314 Dispenser ID: Dispenser Containment Sensor(s) Modet: Dispenser Containment Sensor(s). Model: 7 ShearValve(s). ShearValve(s). X1 Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ❑X ShearValve(s). ShearValve(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; f—I Alarm history report X� PRINTED NAME: KEVIN HAYCOCK SIGNATURE: COMPANY: Tanknolooy PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03101