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MAR-24-2010 08:17 Service Station Systems 408 938 8888 P.03 Monitorin^ystem Equipment Ortification For Use By All Jurisdictions Within The State of•California Authority Cited. Chapter 6.7, Health and.Safely Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A se arate eertific tion or re ort must be prepared for each monit►oring system control gang! 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: USA/Tesoro Bldg,No.: Site Address: 401 W. Kettleman Ln. City: Lodi,CA Zip: 96240 Facility Contact Person: John Contact Phone No.: (209) 368-8787 Make/Model of Monitoring System: Gil EMC Date of Testin.g/Servicing: 2/24/10 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID•01 u Tank!D• 02-Prem ❑ In-Tank Gauging Prole. Model: VR 947990.707 p In-Tank Gauging Probe. Model: VR"7390-107 90-107 ig Annular Space or Vault Scnsor, Model; VR 7843906/49 13 Annular Space or Vault Sensor. Model; VR iX Piping Sump\Trench Sensor(s). Model: vR 794380-649 IN Piping Sump\Trench Sensor(s), Model: VR 794369•ZQ9 o Fill Sump Sensor(s). Model: ❑ Fill Stump Sensor(s). Model: Ig Mechanical Line Leak Detector. model! RJ 196.0s6-5 Mechanical Line Leak Detector. Model: Ra 119.096-5 ❑ Electronic Line Leak rktector. Model: Q Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-1 cvel Sensor. Model: p Tank Overfill\I•iigh-Level Sensor. Model: Q other(specify equipment type and model in Section E on Page 2). Cl Other(specify equipment type and model in Section E on Page 2). Teak ID• Tank ID- T In-'tank Gauging Probe. Model: Q In-Tank Gauging Probe. Model: 13 Annular Space or Vault Sensor. Model: p Annular Space or Vault Sensor, Model; Q Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: p Fill Sump Sensor(s). Modcl: p Fill Sump Sensor(s). Model: C3 Mechanical Line Leak Detector. Model; p Mechanical Line teak Detector. Model; a Electronic Line Leak Detector. Model: ❑ Electronic Linc Lcak Detector. Model; ❑ Tank Overfill\High-Level Sa=. Model: Q 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 F on Page 2). Dispenser ID• ®t-o2 Dispenser lt• 03.04 ❑ Dispenser Containment Sensor(s). Model: Q Dispenser Containment Sensor(s). Model 13 Shear valve(s). IN Shear Valve(s). IN Dispenser Containment Float(s)and Chain(s). tj Nspenser Containment Float(s)and Chain(s). FEUD3 ispenser ID• oll-os Dispenser ID° 07-M Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s), Model; G9 Shear Valve(s), % Shear Valve(s). IN Dispenser Containment Float(s)and Chain(s). 1 Dispenser Contaimncnt Float(s)and Chain(s). Dispenser ID• Dispenser tD° ❑ Dispenser Contaiamcnt Sensor(s). Model: la Dispenser Containment Sensor(s). Model; ® Shear Valve(s) p Shear Valve(s). ❑ Dispenser Comainment Float(s)and Chain(s). Q 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 inspceted/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(c,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): 13 Systene set-ap Q Alarm history report Technician Name(print): Steve Parmenter Signature'. w25� Mfg.Cert.#.: A28780 ICC# 5311561-UT License.No.: 485184 Testing Company Name: Serv.Sta.SYS, Phone No.: (4081971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 2/24110