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Monitoring System Equipment Certification For Use By All Jurisdictions YYithin The StateofFIE Authority Cited:Chapter 6.7, Health andSafety Code; Chapter 16, Division 3, Cif :� ns This form must be used to document testing and servicing of monitoring equipment. certific tion r st be prepared for each monitoring system control panel by the technician who performs the work, tjty jfr? must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agencOrating UST system within 30 days of test date. EMVIROMMEMTAL H A. General Information DEPARTMe V7. I-! Facility Name: NuStar Energy I Bldg.No.: Site Address: 3505 Navy Dr. City: Stockton,CA Zip: 95206- Facility Contact Person: Manager Contact Phone No.: (209) 943-5662 Make/Model of Monitoring System: Incon TS-EMS Date of Testing/Servicing: 5114114 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seryiced: Tank Il�d� Diesel Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: Incon TSP-GJS ❑ Annular Space or Vault Sensor. Model: ® Piping Sump\Trench Sensor(s). Model: Incon TSP-L(LS p Piping Sump\Trench Sensor(s). Model: ❑ 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: ❑ 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). Tank ID• Tank ID• ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: p Annular Space or Vault Sensor. Model: p Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: p Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: p 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). p Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: p Dispenser Containment Sensor(s). Model. ❑ Dispenser Containment Sensor(s). Model: p Shear Valve(s). ❑ Shear Valve(s). Q Dispenser Containment Float(s)and Chain(s). p Dispenser Containment Float(s)and Chain(s). Dispenser IQ* Dispenser ID ❑ Dispenser Containment Sensor(s). Model ❑ Dispenser Containment Sensor(s). Model: p Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID• Dispenser ID: Q Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). p 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/seryiced 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,l have also attached a copy of the; (check alt that apply): Q System set-up ❑ Alarm history report Technician Name(print): Randy Wilkerson Signature: L W_... Mfg.Cert.#.:—1 MOO 7370 t 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: 5114/14