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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: 5/30/12 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID•01-Regu Tank ID• 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 N 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 794390-205 ® Fill Sump Sensor(s). Model: VR 794380-208 ® Fill Sump Sensor(s). Model: VR 794390-205 ® Mechanical Line Leak Detector. Model: Vaporless LD2000 ® Mechanical Line Leak Detector. Model: Vaporless LD2000 ❑ 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:_.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: Vaporless 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 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 ID• 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: ❑ 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; (check all that apply).- ❑ System set-up ❑ Alarm history report Technician Name(print): Ryan Casey Signature: � X19 Mfg.Cert.#.: B38961 ICC# 8057554-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: 5/30/12