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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 13, 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 s stem controlF p%t,by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The o eAp'er`ator must submit a copy of this form to the local agency regulating UST system within 30 days of test date. A. General Information JUL Z�1� Facility Name: NuStar Terminals SAN JOAL2UN C0J-'4_1v Bldg.No.: Site Address: 3505 Navy Dr. Fls=p,t.T H CEPARTMEl`4City: Stockton,CA Zip: 95206- Facility Contact Person: 1-t(, „ e,I Contact Phone No.: (209) 943-5662 Make/Model of Monitoring System:'1k)(2VA.) /�(�' /00/ Date of Testing/Servicing: 712/10 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Inspected/serviced: Tank[D: l,u�, -t7_I ft;� Tank ID- 0 I Tank Gauging Probe. Model: [I In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model:'TS t ❑ Annular Space or Vault Sensor. Model: (Piping Sump\Trench Sensor(s). Model: _710 Piping Sump\Trench Sensor(s). Model: p Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: Q Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: �ank Overfill\High-Level Sensor. Model: 7a _ ❑ Tank Overfill\High-Level Sensor. Model ❑ Other(specify equipment type and model in Section F.on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank[D: Tank Me ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: Cl Piping Sump\Trench Sensor(s). Model: Cl Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Q 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: Dispenser ID' ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). p Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser[D• _ 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). Dispenser[D• Dispenser[D• - ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Q 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 monitoringaqui ment. For any equipment capable of generating such reports,I have also attached a copy of the; (check all that apply): stem set-up "rm history report Technician Name(print): Randy Wilkerson Signature: - Mfg. Cert.#.: �S_3)113 7(0( ICC# �-j�-e«U -U r License.No.: 485184 Testing Company Name: SSS Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Seryicing: 7/2/10