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RECEIVE[) Monitoring System Equipment Certification 2 6 2015 For Use By All Jurisdictions Wiihin The State of California Authority Cited: Chapter 67, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code 6iWp{iMM ENTAL This form must be used to document testing and servicing of monitoring equipment. A sel2aratc certification or [spam m%s 7itoTAllcRrr 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 forni to the local agency regulating UST system within 30 days of test date. A. General Information Facility Name: Shell/Tesoro Site Address: 2448 W. Kettleman Ln. City: Lodi, CA Bide. No.: I i p _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 hoses to indicate specific equipment inspected wre iced: Date of Testing/Servicing: 5/28/15 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 794390.608 ® Annular Space or Vault Sensor. Model. VR 794390.409 ® Piping Sump \ Trench Sensor (s). Model: VR 794360-208 19 Piping Sump \ Trench Sensor (s) Model: VR 794390-206 Fill Sump Sensor (s). Model: VR 794390208 ® Fill Sump Sensor (s). Model: VR 794380-208 Mechanical Line Leak Detector. Model: Vaportess LD2000 ® Mechanical Line Leak Detector. Model: Vaporiess L02000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ Nigh -level Sensor. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Other ( specify equipment tvpe 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: to Piping Sump \ Trench Sensor (s). Model: VR 794380-208 ❑ Piping Sump \ Trench Sensor (s) Model: Do Fill Sump Sensor (s). Model: VR 784380-208 ❑ Fill Sump Sensor (s). Model. a Mechanical Line Leak Detector, Model: Vaportess LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic tine Leak Detector. Model: ❑ 'funk Overfill \ High -Level Sensor, Model: ❑ 'rank Overfill \ High -Level Sensor. Model: Cl 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 [D• 01-02 Dispenser ID• 03-04 p Dispenser Containment Sensor (s) Model. ❑ Dispenser Containment Sensor (s) Model ® Shear Valve (s). I@ Shear Valve (s). (� Dispenser Containment frloat (s) anti Chain (s). ® Dispenser Containment Float (s) and Chain tsi. Dispenser ID: 05-06 Dispenser ID: 07-08 ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model 01 Shear Valve (s). ® Shear Valve (s). ® Dispenser Containment Float (s) and Chain (s). ® Dispenser Containment Float (s) and Chain (s) Dispenser iD• Dispenser Me ❑ 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 (sJ `If thr facility contains more tmtks or dispensers, cop; this form Include intimnation tui everN tank and dispenser at the facilns C. Certification - 1 certify that the equipment identified in this document nas 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, t have also attached a copy of the, ( check ull that apptv): ❑ System set-up ❑ Alarm history report Technician Name (print): Myke Briggs Signature: #4� ff, Mfg. Cert.#. 838235 ICCtJ 8033115 -UT License. No.: 485184 "resting Company Name: Service Station Systems Phone No.: (408) 971-2445 'resting Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 5/28/15