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MONITORING SYSTEM CERTIFICATION d W 7br Use By All Jurisdictions Within the State of Cali Authority Cited:Chapter 6.)alth and Safety Code;Chapter 16,Division 3 Title al/fomia Code of Regulations This toren 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 py of this to"must scertification or ystem ovmer ope�atorust ea prepsr operators us sut mita pyo�Is omn to panel eythe localtagenlcian who performs the work. A cy regulating UST systems within�30 days oft test date.be provided to the tank 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: 12/27/2001 Facility Contact Person: MANAGER Make/Model of Monitoring System: GILBARCO EMC Work Order Number: 2220097 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: UNL Tank ID: SUP In-Tank Gauging Probe. Model: EMC In-Tank Gauging Probe. Model: EMC Annular Space or Vault Sensor. Model: EMC X Annular Space or Vauit Sensor. Model: EMC Piping Sump/Trench Sensor(s). Modal: EMC X Piping Sump/Trench Sensor(s). Model: EMC Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FX1 V X Mechanical Line Leak Detector. Model: FXI V Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfll(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). an an In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vauf Sensor. Model: Piping SumplTrench 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 OverfltMigh-Level Sensor. Model: Tank OverfillIf igh-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). Spenser Dispenser Containment Sensor(s) Model: Dispenser Containment Sensors) Model: Shear Valve(s). Shearvalve(s) ® Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Ispenser - Ispenser ❑ Dispenser Containment Sensor(s) 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). Dispenser ID: Dispenseriu. ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: Shearvalve(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 report; ® Alarm history report 19 PRINTED NAME: ANEIL CHAND SIGNATURE. COMPANY: Tanknology PHONE NO: (800)800-4633 Based on CA form dated 03/01 page 1 of 3