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f t 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: Grace Contact Phone No.: (209)369-3124 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 5/22/18 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: vii e47390-107 ❑ In-Tank Gauging Probe. Model: VR 847390.107 ® Annular Space or Vault Sensor. Model: VR 794390.409 ® Annular Space or Vault Sensor. Model: VR 794390-408 ® Piping Sump\Trench Sensor(s). Model: VR794380.208 ® Piping Sump\Trench Sensor(s). Model: VR 794390-205 N Fill Sump Sensor(s). Model: VR 7W80-208 ® Fill Sump Sensor(s). Model: VR 784380-208 R Mechanical Line Leak Detector. Model: Vaporiess 99-LD20001R ® Mechanical Line Leak Detector. Model: Vaporiess 99-LD2000IR ❑ Electronic Line Leak Detector. Model: ❑ Electronic Linc Leak Detector. Model: ❑ Tank Overfill k 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: 11 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: M Fill Sump Sensor(s). Model: VR 794380-208 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: Vaporiess 99-LD2000IR ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model. ❑ Tank Overfill\High-Level Sensor. Model: p 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). 11 Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser 1D: 05-06Dispenser ID: 07-08 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). 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 alt that apply): ® System set-up ®r�Alarm history lrepopoort Technician Name(print): Brian McPheely Signature: Mfg.Cert.#.: B36746 ICC# 8822062 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: 5122118