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JUN-25-2008 17: 17 Service Station Systems 408 938 8888 P.03 Monitorh _ System EquipmentOertiffcation For use By All.Iurisdictions Within The State of California Authority Cited- Chapter 6,7, Health and Sgfery Code; Chapter 16, Division 3, Title 23, California Code oj'Regulations This form must be used to document testing and servicing of monitorin;equipment. A separate certification or report must be prepared for each monitoring system cont,-p]Ranel 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 system within 30 days of test date. A. General Information Facility Name: USA/Tesoro Bldg. No.: Site Address: 2448 W. Kettleman Ln. @ Lower Sacramento City: Lodi, CA Zip: 95242 Facility Contact Person: Bobbie M Contact Phone No.: (209) 369-3124 Make/Model of Monitoring System:_ Gil EMC Fate of Testing/Servicing: 5128/08 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID•01-Regu Tank ID• 02-Plus 13 In-Tank Gauging Probe, Model; GSCO PA026S0960100 (3 In-Tank Gauging Probe. Model: Gaco PA02650060100 a Annular Space or Vault Sensor. Model: VR 794390-407 Annular Spacc or Vault.Sensor, Model' VR 794390407 IX Piping Sump\Trench Sensor(s). Model: VR 794330.206 Piping.Sump\'french Sensor(s). Model: VR 794390-205 Q( Fill Sump Sensor(s). Model: VR 794330.206 Fill Sump Sensor(s). Model, VR 794390-205 QS Mechanical Line Leak Octector. Modcl: Vaporiess L02000 IX Mechanical Line Leak Detector. Model: yaporteea X02000 ❑ Electronic Linc Leak Detector, Modcl: Nona ❑ Electronic Line Leak Detector. Model- None ❑ Tank Overfill\High-Level Sensor, Modcl: Nene ❑ Tank Overfill\High-Level Sensor. Model: None ❑ Other(specify equipment type and model in Section L on Page 2). p Other(specify equipment type and model in Section h.on Page 2). Tank ID: 03-Prem Tank Ill, Ig In-Tank Gauging Probe. Model; GBCO PA02650960100 ❑ In-Tank Gauging Probe. Model EX Annular Space or Vault Sensor, hfodel VR 794399907 ❑ Annular Spacc or Vault Sensor, Model: Ig Piping Sump\Trench Sensor(s). Model: VR 794990.206 ❑ Piping Sump\Trench Sensor(s). Model: (g Fill Sump Sensor(s). Model: VR 794390.20e ❑ Pill Sump Sensor(s). Model: Mechanical line Leak Detector. Model: Vapodoss X02000 ❑ Mechanical Linc Leak Detector. Model; ❑ Electronic Line Leak Detector. Model: None Cl Electronic Linc Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model. None ❑ Tank Overfill\High-Level Sensor. Model-. ❑ Other(specify equipment type and model in Section Fi an Page 2). ❑ Other(specify equipment type and model in Section E on Pate 2). Dispenser ID: 01.02 Dispenser ID: 03-04 (] Dispenser Containment Sensor(s). Model: None ❑ Dispenser Containment Sensor(s). Model: None Qs Shear Valve(s). [X Shear Valve(s). IS Dispenser Containment Float(s)and Chain(s). QI Dispenser Containment Float(s)and Chain(s). Dispenser IU: 05-06 Dispenser ID: 07-08 ❑ Dispenser Containmcnt Sensor(s), Model, None ❑ Dispenser Containmcnt Sensor(s). :vlodcl: None Shear Valvc W. IX Sheat Valve(s). (X Dispenser Containment Float(s)and Chain(s). (a Dispenser Containment Flout(s)and Chain(s). Dispenser ID- Dispenser 10; ❑ Dispenser Containmcnt Sensor(s). Model: ❑ Dispenser Containmcnt Scnsor(s). Modcl, ❑ Shear Valve(s). ❑ $hear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). Cl Dispenser(.ontainmcnt Float(s)and Chain(s). "if tht facility contains more tanks or dispcnscrs,copy this form. Include information for every tank and dispenser at the facility C. Certification- 1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures`checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of gcncrating such reports,I have also attached a copy of the; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name(print): Randy Wilkerson Signature: Mfg. Cert,#.,, A32404 ICOR 5258560-UT License_No.: 485184 Testing Company Name: Serv. Sta. Sys. Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose CA 95112 Date of Testing/Servicing: 5/28/08