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Monitoring System Equipment Certification For Use By All Jurisdictions Within The State of California L'_RjLw �.. 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 reYnorLUS416 prepared for each monitoring system control 2aanel by the technician who performs the work. A copy of this fortir ttlttc�., tpvavided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating U Tsystem within 30 days of test date. A. General Information Facility Name: ShelliTesoro 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 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 5116/16 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 ® 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 794380-206 ® Fill Sump Sensor (s). Model: VR 794380-208 ® Mechanical Line Leak Detector. Model: Vaportess LD2000 ® Mechanical Line Leak Detector. Model:yaporiess 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 1D: 03 -Diesel Tank ❑ ID: In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Model: VR 847390-107 ® 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 794380.208 ❑ Fill Sump Sensor (s). Model: ® Mechanical Line Leak Detector. Model: Vaporiess 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: FDispenser 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 Cl Alarm history report Technician Name (print): Myke Briggs Signature: �s 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: 5/16/16