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MONITNG SYSTEM CERTIFICATION e By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,He and Safety Code;Chapter 16, Division 3 Title 23, mia 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 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: CONOCO PHILLIPS#2705445 City: STOCKTON CA Zip:95210 Site Address: 1206 E MARCH LANE Contact Phone No: 478-6487 Date of Testing/Service: 05/12/2005 Facility Contact Person: MANAGER Make/Model of Monitoring System:VRTLS350 Work Order Number: 2236215 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced TanklD: 1 TanklD: 2 71 In-Tank Gauging Probe. Model: OAP X1 In-Tank Gauging Probe. Model: CAP X Annular Space or Vault Sensor. Model: 409 21 Annular Space or Vault Sensor. Model: 409 X Piping Sumpfl-rench Sensor(s). Model: 206 21 Piping Sump/Trench Sensor(s). Model: 206 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FE PETRO 2Mechanical Line Leak Detector. Model: FE PETRO 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: TanklD: X In-Tank Gauging Probe. Model: CAP In-Tank Gauging Probe. Model: -Xi Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Model: X Piping SumpfTrench Sensor(s). Model: 205 Piping Sump/rrench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: LD2000 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: 5/6 0 Dispenser Containment Sensor(s) Model:206 X Dispenser Containment Sensors) Model: 208 XJ Shear Valve(s). X Shear Valve(s) El Dispenser Containment Float(s)and Chain(s). 7 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3/4 Dispenser ID: 7/8 O Dispenser Containment Sensor(s) Model:208 Dispenser Containment Sensor(s). Model:208 RI Shear Valve(s). Shear Velve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9/10 Dispenser ID: 0 Dispenser Containment Sensor(s) Model:208 Dispenser Containment Sensor(s), Model: QX Shear Valve(s). Shear Velvets). 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): E System set-upXO Alarm history report//y��// Technician Name(print): RAYMOND SIMMS Signature: ' y"—� Certification No.: 006-05-0282 License.No.: Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8501 N. MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 05/12/2005 Page 1 of 3 Based on CA form dated 03/01 Monitoring System Certification