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Monitoring System Equipment Certification For Use By All Jurisdictions Within The State of California 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 Mort must be prepared for each monitoring 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/opRrECEATO the local agency regulating UST system within 30 days of test date. A. General Information Facility Name:Mobil/Tesoro MAR 22 2017 Bldg. No.: Site Address: 401 W. Kettleman Ln. la Facility Contact Person: Zip: 95240 (209) 368-8787 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 2123/17 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID• 01-Regu Tank ID• 02 -Prem ® In - Tank Gauging Probe. Model: GBCo PA2660960200 11 In - Tank Gauging Probe. Model: GBCo PA2650960200 ® Annular Space or Vault Sensor. Model; VR 794390420 ® Annular Space or Vault Sensor. Model: VR 794390460 Piping Sump \ Trench Sensor (s). Model; VR 794350-266 ® Piping Sump \ Trench Sensor (s). Model: VR 784380-266 p Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ® Mechanical Line Leak Detector. Model: RJ 116.056.5 ® Mechanical Line Leak Detector. Model: RJ 116.056-5 ❑ 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). Tank Iii,; Tank I ❑ 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% 01-02 Dispenser ID• 03-04 ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: ® Shear Valve (s). ® Shear Valve (s). Dispenser Containment Float (s) and Chain (s). 0 Dispenser Containment Float (s) and Chain (s). Dispenser ID- 06-06 Dispenser ID' 07-08 ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: ® Shear Valve (s). ® Shear Valve (s). ® Dispenser Containment Float (s) and Chain (s). ® Dispenser Containment Float (s) and Chain (s). Dispenser ID' Dispenser ID• ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: ❑ Shear 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 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 moultoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the; (checksH thatspply): B System set-up IR Alarm history report Technician Name (print): Kris Bell Signature: Mfg. Cert.#. B33709 ICC# 5297793 -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: 2/23/17