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0 • MONITORING SYSTEM 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 report 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/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: Nella Oil #427 Site Address: 3300 Waterloo RD. Facility Contact Person: Kristin Ford Make/Model of Monitoring System: Gilbarco EMC B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: City: Stockton Contact Phone No.: Bldg. No.: Zip: 95205 Date of Testing/Servicing: 12 /06 /2005 Tank ID: Gasoline - 87 Tank ID: Gasoline -89 M In -Tank Gauging Probe. Model: 0847390-109 ■ In -Tank Gauging Probe. Model: 0847390-109 0 Annular Space or Vault Sensor. Model: 0794390-420 ■ Annular Space or Vault Sensor. Model: 0794390-420 ■ Piping Sump / Trench Sensor(s). Model: 0794380-208 ■ Piping Sump / Trench Sensor(s). Model: 0794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ■ Mechanical Line Leak Detector. Model: FE -Petro MLD ■ Mechanical Line Leak Detector. Model: Red Jacket FX ❑ 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 a and model in Section E on Pae 2). ❑ Other (specify equipment a and model in Section E on P e 2). Tank ID: Diesel Tank ID: 0 In -Tank Gauging Probe. Model: 0847390-109 ❑ In -Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: 0794390-420 ❑ Annular Space or Vault Sensor. Model: E Piping Sump / Trench Sensor(s). Model: 0794380-208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ■ Mechanical Line Leak Detector. Model: Red Jacket FX ❑ 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 a ui ment a and model in Section E on Page 2). ❑ Other (speciLy a ui ment type and model in Section E on P2je 2). Dispenser ID: 1 Dispenser ID: 2 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ■ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). E Dis nser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 5-6 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: E Shear Valve(s). M Shear Valve(s). E Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). Dispenser ID: 7 Dispenser ID: 8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: N Shear Valve(s). ■ Shear Valve(s). EDis enser Containment Float(s) and Chain(s). ■ Dispenser Containment Floats 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 Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): Q System set-up x❑ Alarm histo eport Technician Name (print): Mike Lawrence Signature'--L�4�>� Certification No.: 006-05-2104 License. No.: 617238 Testing Company Name: Walton Engineering, Inc. Phone NoA 916 ) 373-1152 Site Address: 3900 Commerce Drive, West Sacramento, CA 95691 UN -036 - 1/4 COPA: San Joaquin Co. Env. Health INSPECTOR: Michelle Le Page 1 of 4 WALTON — = i'4 -� s E` *A l ex 1 N Cr www.unidocs.org Date of Testing/Servicing: 12 /06 /2005 Rev. 06/04/01