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JUL-11-2011 10:48 Service Station Systems 408 938 8888 P.02 Monitoring System Equipment Certification k'or Use By All,lurisdiations Within The State of California Authority Cited., Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Calilornia Code of Hegulations This form must be used to document testing and servicing of monitoring equipment- A separate certification Qr rCPort must he prepared for each monitoring system control panel by the technician who pertbrms the work, A copy of this form must be provided to the tank system owncr/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: NuStar Energy Bldg,No., Site Address: 3505 Navy Dr. City: Stockton, GA Zip: 95206- Facility Contact Person: Daniel Contact Phone No.: (209)943-5662 Make/Model of Monitoring System: Incon TS- 1001 Date of Testing/Servicing: 6/27/11 8. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank l '01- VM&LA&I Tank In, ❑ In-'tank Gauging Probe, Model: ❑ in-"rank Gauging Probe, Model: Cg Annular Space or Vault Sensor. Model: Incon TSP- tS ❑ AOmarlr Spaeo or Vault.Scnsor. model: 19 Piping Sump\Trench Scnsor(s). Model: Ineon TSP-D(h ❑ Piping Sump t Trench Sensor(s). Model, ❑ Fill Sump Sensor(s). Model; ❑ Fill Sump Sensor(s). Model. ❑ Mechanical Line Leak Detector, Model: ❑ Nlechnnici l Line Leak Dewctor. 'Model: ❑ Electronic Line Leak Demeter. Model: ❑ Eloctronic Linc Leak Detector. Model: ® Tank Overfill\High-Level Scnsor, Model: ll ttf)n YSP-111.5 ❑ Tank Overfill t High-f,evel Sensor. 'Model: ❑ OCher(specify equipment type and model in Section L on Page 2), ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID _ Tank ID• --- ❑ In-Tank[musing Probe. Model: ❑ In-'Tank Gauging Probe, Model: ❑ Annular Space or Vault Sensor. Modcl: ❑ Annular Space or Valtlt Scnsor. Model; ❑ piping Sump\Trench Sensor(s). Model: 0 Piping Stamp\Trench Sensor(s). Model: ❑ Pill Sump Sensor(s). Model: Q Fill Sump Senior(s). Model; ❑ Mechanical Line Leak Detector, Model: ❑ Mechanical tine Leak Detector. Model; ❑ Llectrtmic Line Leak Detector, Modcl: _— ❑ Electronic Linc Leak Detector. ivfodel ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Mode:: ❑ other(specify e(luiprtrertt typo and model in Section E on Page 2). ❑ Other•(specify equipment type and model in Section F.on Paec 2). Dispenser iD Ilispenser IQ; (] Dispenser Containment Sensor(s). Model: ❑ Dkpcnscr Containment Sensor(s), Model: Q Shear Valve(s). ❑ Shear Valve(s), ❑ Dispenser Contaimnent Float(s)and Chain(i). ❑ Dispenser Ccntainmcnt Floitt(s)and Chain(s). Dispenser IDT Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shcar Valve(s). ❑ Shear Valve(s). [� Dispenser Containment float(S)and Chain(s). ❑ L)iSpetlser C'ojiW mcnt Float(s)and Cham(s). Dispenser ID= Dispenser lips ] Dispenser Containment Sensor(s), Model ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(S). ❑ Shear Valve(s). ❑ Dispenser Containment Hoak(s)and Chain(S). (] Disncnscr Containment Float(s)and Chain(s). 'lf the facility contains more tanks or dispensers,copy rhis form.include information for every tank and dispenser at the facility C, Certification- I certify that the equipment identified in(his doctltnent 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 file layout of monitoring equipment For any equipment capable of generating such reports,t have also attached it cupy of file; (cheek all that apply): ❑ System set-up ❑ Afarin history report Technician Name(print): Randy Wilkerson Signature: /'.y.14 - mirg. Cert.#.: 19194013101 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, GA 95112 Date of Testing/Servicing: 6/27/11