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..*. ei i 0140 171701 This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the WRI a separate oartilleation or report umd be prepared for each monitoring system cnel by the technician who porlorms the work. A copy of this form must be provided to the tank system ownetioperator. ThO owyneff6peWor r6ust—submif jjcopy of this form to ma tonal agency regulating UST systems within 30 days of test date. A. General lnfbnna#m Facility Name: TEXACO TRUCK STOP Ste Address: 3940 N.TRACY BLVD Facility Contact Person: DEBBIE Make/Model of Monitoring System: GILOBARCO B. Inventory of Equipment Tesitedl/Cerfifled City: TRACY �r M Date of Testing/Service: 10/29/20011 Work Order Number: 2219141 Check the appropriate boxes to indicate specific equipment inspectediserviced M • if the facility -con—tains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. �*Wql;TPID I certify that the equipment identified in this document was inspected/Servieed in accordance with the manufacturers' guidelines. Attached to this certification Is information (e.9 manufacturers' checklists) necessary to verity that this information is correct. and a Site Plan 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 report; [] Alarm history report E] PRINTED NAME:MATT HEMMINGSEN SIGNATURE. COMPANY: Tanknology PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 03101 - -- ------- jrTank ID. 2 In -TW* Gauging Probe. Model: 8473 I. -Tank Gouging Probe. Model: 8473 Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping SumprTranch Sensor(s). Model: 208 Piping Sump/Trench SeI Model: 208 FRI Sump Sensoir(s). Model: Fit Sump Sensor(a). Model: Mechanical Line Leak Detector. Model.. 04177 EJ Mechanical Line Leak Detector. Model: 78293 Electronic Line Leak Detector. Model: FLAPPER I- 91 Electronic Line Leak Detector. Model: Wj Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: FLAPPER XOther (specify equipment type and model In Section E on page 2). Other (specKy equipment type and model in Section E on page 2). tn-Tank Gauging Probe. Model: 3 In -Tank Gauging Probe. Model.. 8473 Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: iiiAnnular Piping Sumprrrench Sensor(s). Model- Piping Sump/Tirench Sensor(a). Model: 208 IF FIT Sump Ssnsor(s)Model: ■Fill Sump sensoqs). Model: Mechanical Line Leak Detector. Model: 06445 Mechanical Line Leak Detector. Model: 06446 Electronic Line Look Detector. Modeiiil: Electronic Line Look Detector. Model: Tank Ovarffil/High-Level[ Sensor. Model: FLAPPER Tank Overfilliffth-Level Senw. model.. FLAPPER Other (specify equipment type and model in Section E on page W Other (specify equipment type and mod.1 in Section E on page 2). I rz I itispenser lu: (16 -- Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) modefiil: ShearValvel(s). Shear Velvets) MDispenser Containment Floet(s) and Chain(s). Dispenser Containment Flost(s) arid Chaln(e). -jilepenser lV. 314•1 riser IU: ALL UILUEL Dispenser C.Marriment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ShearValve(s). ShearValve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Ftoal(s) and Chain(s). Dispenser ID: 5/6 -I Dispenser ID: i DisperiserContainmenlSensor(s) Model: Dispenser Containment Sensor(s). Model: (a). Shearvalve(s). r Containment Float(s) and Chaini(s). Dispenser Containment Flost(s) and Chain(s). • if the facility -con—tains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. �*Wql;TPID I certify that the equipment identified in this document was inspected/Servieed in accordance with the manufacturers' guidelines. Attached to this certification Is information (e.9 manufacturers' checklists) necessary to verity that this information is correct. and a Site Plan 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 report; [] Alarm history report E] PRINTED NAME:MATT HEMMINGSEN SIGNATURE. COMPANY: Tanknology PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 03101