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lcu-1: 1`11 D Monitoring System Equipment Certi�. JUL 2 7 2017 For Use By All Jurisdictions Within The State of California' ��'Ta� HE�LT Authority Cited:Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code'"�e WCbj"EN7- H This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring s�stem 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: Manager Contact Phone No.: (209)369-3124 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 5116/17 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: VR 847390.107 ❑ In-Tank Gauging Probe. Model: VR 847390-107 ® Annular Space or Vault Sensor. Model: VR 794390-409 Do 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 794390-20e ® Fill Sump Sensor(s). Model: VR 794380-208 19 Fill Sump Sensor(s). Model: VR 794380-208 ® Mechanical Line Leak Detector. Model: yaporless LD2000 ® Mechanical Line Leak Detector. Model: Vaportess LD2000 ❑ Electronic Linc 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 Illi, 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 794380-208 ❑ Fill Sump Sensor(s). Model: all Mechanical Line Leak Detector. Model: yaponess 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 I% 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: 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 ® Alarm history report W Technician Name(print): Randy Wilkerson Signature: Mfg.Cert.#.: A32404 ICC# 5258560-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: 5116/17