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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 monitorin a ui ent. A separate certification or report must be prepared for each monitoringsystem contm%91" tni e the work. A copy of this form must be provided to the tank system owner/operator. Theo ra r �t su form to the local agency regulating UST system within 30 days of test date. A. General Information JUN 2 7 2013 Facility Name: Shell/Tesoro Bldg. No.: Site Address: 2448 W. Kettleman Ln. ENVIRONMENTAL City: Lodi, CA Zip: 95242 umm-rw nr-PARTMENI Facility Contact Person: Manager Make/Model of Monitoring System: Gil EMC B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Contact Phone No.: (209) 369-3124 Date of Testing/Servicing: 5129/13 Tank ID• 01-Regu Tank ID• 02 -Prem ❑ In - Tank Gauging Probe. Model: VR 847390.107 ❑ In - Tank Gauging Probe. Model: VR 847390-107 I& Annular Space or Vault Sensor. Model: VR 784390-409 ® Annular Space or Vault Sensor. Model: VR 794390-909 ® 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: Vaporiess LD2000 13 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: Do Mechanical [.me Leak Detector. Model: Vaponess 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: 0 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 I% 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 ❑ s ory repor Technician Name (print): Raamon Frazier Mfg, Cert.#.: B37362 ICC# 8020732 -UT Signature: 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: 5129/13