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Monitoring System Equipment Certification For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16,Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. 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 system within 30 days of test date. A. General Information Facility Name:Shell/Tesoro Bldg.No.: Site Address: 2448 W. Kettleman Ln. City: Lodi, CA Zip: 95242 Facility Contact Person: Manager Contact Phone No.: (209)369-3124 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing; 10/25/12 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspectedlserviced: Tank IQ#01-Regu Tank We 02-Prem ❑ In-Tank Gauging Probe. Model: VR 847390-107 ❑ In-Tank Gauging Probe. Model: VR 847390.107 ❑ Annular Space or Vault Sensor. Model: VR 794390-409 ❑ Annular Space or Vault Sensor. Model: VR 794390-409 ❑ Piping Sump\Trench Sensor(s). Model: VR 794380-208 ® Piping Sump\Trench Sensor(s). Model: VR 794380-208 p Fill Sump Sensor(s). Model: VR 794380.208 ❑ Fill Sump Sensor(s). Model: VR 794390-205 p Mechanical Line Leak Detector, Model: Vaportess LD2000 ❑ Mechanical Line Leak Detector. Model: Vaporless L02000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Ove ill\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: 03-Diesel Tank ID: ❑ in-Tank Gauging Probe. Model: VR 847390-107 ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: VR 794390-409 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: VR 794380.208 ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: VR 794390-205 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: Vaportess LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ "rank 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 ID: 01-02 Dispenser ID: 03-04 ❑ 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: 05-06 Dispenser Ill: 07-08 ❑ 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• Dispenser ID- ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 13 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 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 generating such reports,I have also attached a copy of the; (cheek all that apply): ® System set-up 0 Alarm history report Technician Name(print): M,yke Briggs Signature. Mfg.Cert.#.: B38235 iCC# 8033115-UT License.No.; 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 10/25/12