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{ ' MONITORING SYSTEM CERTIFICATION r Use By All Jurisdictions Within the State of Cal#b Authority Cited: Chapter 6. , ealth and Safety Code, Chapter 16, Division 3 Title 23, /forma Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, a separate certification or report must be prepared for each monitorina system 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 systems within 30 days of test date. A. General Information Facility Name: ULTRAMAR 513 Site Address: 401 W. KETTLEMAN LANE S. LEE AVE Facility Contact Person: MGR - City: LODI Contact Phone No: 368-8786 Date of Testing/Service: 01/22/2002 Make/Model of Monitoring System: GILBARCO EMC Work Order Number: 2220578 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced CA Zip: 95240 Tank ID: 1 Tank ID: 2 X In -Tank Gauging Probe. Model: 2650960200 X In -Tank Gauging Probe. Model: 2650960200 X Annular Space or Vault Sensor. Model: 2591144000 ® Annular Space or Vault Sensor. Model: 2591144000 71 Piping Sump/Trench Sensor(s). Model: 2592000001025920000010 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FX1 V FXI Mechanical Line Leak Detector. Model: FX1 V Electronic Line Leak Detector. Model: ElElectronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: ATG X Tank Overfill/High-Level Sensor. Model: ATG Other (specify equipment type and model in Section E on page 2). 1:1Other (specify equipment type and model in Section E on page 2). TanklD: TanklD: 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: 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: 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 : 1/2 Dispenser ID: 3/4 ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: X❑ Shear Valve(s). X Shear Valve(s) ❑X Dispenser Containment Float(s) and Chain(s). X Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). 71 Shear Valve(s). X Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser lD: ® Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: QShear 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 manufacturers' guidelines. Attached to this certification is information (e.g manufacturers' checklists) necessary to verify that this information is correct. and a Site 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 report;X❑ Alarm history report rM PRINTED NAME -JEFF CONGER SIGNATURE: COMPANY: Tanknolopy PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 03/01