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f 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 monitories 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: VALERO Bldg.No.: Site Address: 1001 YOSEMITE City: MANTECA Zip: 95336 Facility Contact Person: DILLON Contact Phone No.: (209) 824-9282 Make/Model of Monitoring System: TLS 3350 Date of Testing/Servicing: 6/29/2009 B. Inventory of Equipment Tested/Certified Check the apgropriate boxes to indicate s cific a ui ment inspected/serviced: FTankID: 87 Tank ID: 91 In-Tank Gauging Probe. Model: MAG-1 ®In-Tank Gauging Probe. Model: MAG4 Annular Space or Vault Sensor. Model: 409 ®Annular Space or Vault Sensor. Model: 409 Piping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 ❑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). Tank ID: DSL Tank ID: ®In-Tank Gauging Probe. Model: MAG-1 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 409 ❑Annular Space or Vault Sensor.' Model: ®Piping Sump/Trench Sensor(s). Model: 208 ❑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 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). 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). FDipnser Dispenser ID: tainment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: . ❑Sheaz Valve(s). tainment 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 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 capablejf generating such reports,I have also attached a copy of the report;(check all that apply): ❑System set-up ❑Alarm 9wry report Technician Name(print): HEATH CEVER Signature: Certification No.: A27562 License.No.: 5236756-UT Testing Company Name: SST-SERVICE STATION TESTING Phone No.:(209) 465-5577 Testing Company Address: PO BOX 31465 STOCKTON CA 95213 Date of Testing/Servicing: 6/29/2009 Page 1 of 3 Rev(2/08)