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MAR-18-2009 11:13 Service Station Systems 408 938 8888 P.03 Monitoria System e e i cai For Use By All,1urisdictfons Within The State of Cali ornia Authority Cited: Chapter 6.7, Health and Safety 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 separate certification or reDOrt must bg prepared for each monitprinf,system control Mel 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 LUST system within 30 days of test elate. A. General Information Facility Name: USA/Tesoro Bldg.No.: Site Address: 401 W. Kettleman Ln.a Hutchins City: Lode, CA Zip: 95240 Facility Contact Person_Manager - Contact Phone No. (209)368-8787 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 2124/09 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inwocd/serviced: Tank 10Q•01 u Tank ED; 02-prem C In-Tank Ganging Probe, Model: VR 847390-947 p In-Tank Gauging Probe. Model: VR 947300.907 IS Annular Space or Vault Sensor. Model: VR 794390.410 IN Annular Space or Vault Sensor. Model; VR 794390420 1l Piping Sump\Trench Sensor(s). Model: VR 794494.208 Q3 Piping Sump\Trench Sensor(s). Model: VA 7114 380-208 ❑ Fill Sump Sensor(s). Model; None 13 Fill Sump Scnsor(s). Model: Naw IN Mechanical Lino Leak Detector. Model:__ye ss LD3404 T M Mechanical Line Leak Detector. Model: RJ 190.069.$ ❑ Electronic Linc Lcak Detector. Model: Nage ❑ Electronic Line Leak Detector. Model; N-a C3 Tank Overfill\High-Level Sensor. Model: Nave p Tank Overfill\High-Level Sensor, Model: Nora p 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). Tank ID• Tank ID• O In-Tank Gauging Probe. Model; ❑ In-Tank Gauging Probe. Model; p Annular Space or vault Sensor. Model: p Annular Spacc or Vault Sensor. Model: El Piping Sump\Trench Sensor(s). Model: p Piping Sump 1 Trench Sensor(s). Model: p Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model,- 13 odel;13 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 13 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). l7 Other(specify equipment type and model in Section E on Page 2). Dispenser ID• 01.02 Dispenser TD• 03-04 ❑ Dispenser Conlairrmont Sensor(s). Model: Nara ❑ Dispenser Containment Sensor(s). Model: N iX Shear Valve(s). a Shear Valve(s). 9 Dispenser Containment Float(s)and Chain(s). 13 Dispenser Containnrcrit Float(s)and Chain(s). Dispenser ILD• 05-06 Dispenser IDj07.08 . Cl Dispenser Containment Sensor(s). Model: N6na C3 Dispenser Containment S m,4or(s). Modol; None is Shear Valve(s). 11 Shear Valve(s). 11 Dispenser Containment Float(s)and Chain(s). 13 Dispowor Containment Float(s)and Chain(s). Dispenser IDt _ _ Dispenser ID° E3 Dispenser Containment Sensor(s). Model: 17 Dispenser Containment Sensor(s). Model: D Shear Valve(s). 13 Shear Valve(s). p Disperser Containment Float(s)and Chain(s). p 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.Cert fleation- I 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 Pian 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 ❑ Alarm history report Technician Name(print): Bryan Lundien Signature: Mfg.Cert_#.: B36094 ICC# 8001468•U License.No.: 486184 Testing Company Name: Sent.Sta.Sys. Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave., Sart Jose CA 95112 Date of Testing/Servicing: 2/24109