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. h� MONITORING SYSTEM CERTIFICATION r Use By All Jurisdictions Within the State of Calrfo , CaliforniaCode of Regulations Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3 Title 233, This form must be used to document testing and servicing of monitoring equipment. N more than one monitodng system control panel is installed at the facility,a separate certification r report must ba I pa ed f ea h mo itoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system ownerlopemtor. 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: 95336 Facility Name: ULTRAMAR 492 City: MANTECA Site Address: 470 N MAIN ST Contact Phone No: 823-1344 Date of Testing/Service: 12/19/2001 Facility Contact Person: MANAGER Make/Model of Monitoring System: GILBARCO EMC Work Order Number: 2220022 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced TanklD: UNL TanklD: SUP X In-Tank Gauging Probe. Model: EMC X In-Tank Gauging Probe. Model: EMC X Annular Space or Vault Sensor. Model: FMC Annular Space or Vault Sensor. Model: EMC 71Piping Sump/Trench Sensor(s). Model: EMC Piping Sump/Trench Sensor(s). Model: EMC Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: RJFX1 V Mechanical Line Leak Detector. Model: RJ FX1 V Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank OveKll/High-Level Sensor. Model: Tank OveKll/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). TankID: TanklD: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench 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). F r : 1-2 Dispenser 1D:enser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: rValve(s). Shear Valves) enser Containment Floats)end Chain(s). XDispenser Containment Float(s)and Chain(s). er ID: 5-6 Dispenser ID: 7-8 enser Containment Sensors) Model: Dispenser Containment Sensor(s). Model: r Valve(s). Shear Valve(s). X Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ 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). •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; X❑ Alarm history report El PRINTED NAME' ANEIL CHAND SIGNATURE: �,p COMPANY: Tanknology — PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03101