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Monitoring System Equipment Certification For Use By All Jurisdictions R71hin 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: Grace Contact Phone No.: (209) 369-3124 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 5/29/14 B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate sneeifte eauinment insnected/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 a Annular Space or Vault Sensor. Model: VR794390.409 ® Annular Space or Vault Sensor. Model: VR 794390.409 a Piping Sump \ Trench Sensor (s). Model: VR 794380408 ® Piping sump \ Trench Sensor (s). Model: VR 794390.205 a Fill Sump Sensor (s). Model: VR 794780-208 ® Fill Sump Sensor (s). Model: VR 794380.208 I@ Mechanical line Leak Detector. Model- VapodessLD2000 ® Mechanical Line Leak Detector. Model: VapodessLD2000 ❑ Electronic tine Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High -Levet 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 IQ* 03 -Diesel Tank IQ: ❑ In - Tank Gauging Probe. Model: VR 847390-107 ❑ In - Tank Gauging Probe. Motel: Do Annular Space or Vault Sensor, Model: VR 794390409 ❑ Annular Space or Vault Sensor. Model: a Piping Sump \ Trench Sensor (s). Model: VR 794380208 ❑ Piping Sump \ Trench Sensor (s). Model: a Fill Sump Sensor (s). Model: VR 794380.208 ❑ Fill Sump Sensor (s). Model: a Mechanical Line Leak Detector. Model: Vaporiess L02000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High-level Sensor. Model: ❑ Tank Overt -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). Dispenser ID* 01-02 Dispenser ID- 03-04 ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: a Shear Valve (s). a Shear Valve (s). a Dispenser Containment Float (s) and Chain (s). a Dispenser Containment Float (s) and Chain (s). Dispenser IDL 05-06 Dispenser ID* 07-08 Q Dispenser Containment Sensor (s) Model: ❑ Dispenser Containment Sensor (s). Model: a Shear Valve (s). a Shear Valve (s). a Dispenser Containment Float (s) and Chain (s). a Dispenser Containment Float (s) and Chain (s). Dispenser ID, Dispenser ID• ❑ Dispenser Containment. Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: p 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 - 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 generating such reports, i have also attached a copy of the, ( check all that app1Y): ❑ System set-up ❑ Alarm history report Technician ;`lame (print): Kris Bell Signature: Mfg. Cert.#.: B33709 ICC# 5297793 -UT License. No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 96112 Date of Testing/Seryicing: 5/29/14