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MAR-23-2011 11:36 Service Station Systems 408 938 8888 P.03 Monitoring S'Ystem Equipment Certification For Use By,411.htri.sdictions Within The State of California Authority Cited.,Chapter 6.7, Health and Safety Code;Chapter 16,Division 3, Title 23, California Come of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certificatign or report must be Vreparcd for each monitoring system control panel by the technician who perfarrns 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[1ST 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: 95240 :Facility Contact Person: Mike Contact Phone No.: 209 368.8787 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 2/23/11 _ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/servieed: Tank ID•01-Regu _ Tank,02-Prem ❑ In-Tank Gauging Prnhc, Model: VR 847390-107 ❑ In-Tank Gauging probe. Model: VR 947390.107 a Annular Spacc or vault Sensor. Model: VR 794M-420 a Annular Space or vault Sensor. Model: VR 794sso-420 is Piping Sump\Trench Sensor(s). Model: VR 794180_-20_8 11 Piping Sump\Trench Sensor(s), Model: w:724sa0.2116_ ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: W Mechanical Linc Leak Detector. Model; RJ 11"W$ M Mechanical Line Leak T)ctcctor. Model: RJ iiti- 5 ❑ Electronic Line Leak Detector. Model: 1.3 Electronic Line Leak Detector. Model: 0 Tank Overfill\high-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Odtcr(specify equipment type and model in Section E on Page 2). Tank Tank 11)? ❑ In-Tank Gauging Probe, Model: ❑ in-Tank Gauging Probe. Model: (3 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: ❑ Pill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector, Model: Mechanical line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Linc Leak Detector. Model: ❑ Tank Overfill\High•Lowl Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(apet:iry equipment type and model in Section E on Page 2). Disppenser IDr 01-02 Dispenser03-04 II!; C) 15ispenser Containment Sensor(s). Model- ❑ Dispenser Containment Sensor(s). Model: s Shear Valve(s). a Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). po Dispenser Containment Float(s)and Chain(s). Dispenser CR: 05.06 _ Dispenser ID' 07-08 ❑ Dispenser Containment Sensor(s). Model: ❑ Dizponscr Containment Sensor(c). Model: Shear Valve(s). 51 Shear Valve 0), Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Disperaser ID' Dispenser ID• C] 6ispenser Containment Sensor(a). Model: ❑ Dispenser Containment Sensor(s). Modal: _ ❑ Shear Valve(s). 13 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 dfspenscr at the facility C.Certification- I certify that the equipment identified in this document was Inspected/serviced in accordance with the manufacturer's guldellim. Attached to this Certilieadou is information(e g.manufactures'cbrxklists)necessary to verify that this Information is correct and a Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the; (check aft that xppfy). Cl System set-up ❑ "Alarm htonry report Technician Name(print):JeSSe Rodriguez Signature: ��:� Mfg.Cert.#.: 837358 ICC# 8024952-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: 2123/11