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08/05/2003 08:31 1209365*-43 TANKNOLOGY PAGE 09/11 q,%0 Y ONITORING SYSTEM CERTIFICATION0 se Sy All Jurisdictions Within the state of Callfomia 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, if more than one monitoringtem control � pane(is installed at the facility,s separate =ilioation or report must be Dreoared!or each monitorinr�cvstem tml Danjby 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 Copt'of this form to tho local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: ULTRAMAR 641 City: STOCKTON CA Zip:95210 Site Address: 1210 E.HAMMER LANE Contact Phone No!477-3111 ®WEST LANE Facility Contact Person: MGR-VALERIE Date of Testing/Service; 08/04/2003 Make/Model of Monitoring System: GILBARCO/EMC Work Order Number. 2227731 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Inspected/serviced Tank iD: Tank ID: In-'tank Gauging Probe. Model; fn-Tank Gauging Probe. Model; X Annular Space or Vauk Sensor. Modal; 40 Annular Space or Vault Seng. Model: 460 X Piping Sump/Trench Sensor(s), Model: 208 Piping Sump/Trench Sensor(s). Model; 208 X Fill Surnp Sensor(s), Model: 2W Fill Sump 3ewr(s). Model: 208 Mechanical Line Leak Detector, Model; FX)V FX1 V Mechanical Lina Leak Dotector. Model: Electronic Line Leak Detector. Model: MAG, Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: X Tank OverfilUiiigh-Level Seng, Model: MAG Other(specify equipment type and model In Section E on page 2). Other(specify equipment type and model M Section E on pago 2). Tank ID: 3 ankle: in-Tank Gauging Probe, Model: In-Tank Gauging Probe, Madel: X Annutar Space or Vault Sensor. Model: 460 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 208 — Piping Sump/Trench Sonsor(s). Model X Fill Sump Sensor(s). Model: 208 Fin Sump Senaor(s). Model: X Mechanical Line Leak Detector. Modei: FX1 V Mechanical Line Leak Detector, Model,, Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model; X lank OverflllMfgh-1®vet Sensor. Madel: MAG Tank Overlill/High-Level Sensor. I: Other(spocify equipment type and model in$action E on (sped page 2). Other equipment ) IY type end modal in SeotlOn E on page Z, lspenser _ Dispenser PD: Dispenser Containment Sonsor(s) Model: Dispenser Containment Sensors) Model: X Shear Valve(s). X Shear Valva(s) X Dispenser Containment Float(s)and Chain(s). X-1 Dispenser Containment Floats)and Chaln(s). Dispenser ID: 5/6 Dispenser JD: 7/8 Dispensor Containment Sonsor(s) Model: Dispenser Containment Sensor(s), Model; X Shear Valve(s). Shear Valve(s). X Dispenser Contefnmant Floats)and Chaln(s). Dfapensor Containment Fkmt(s)and Chain(s). Dispenser( : Dispenser ID: Dispensor Containment Sensors) Model: Dispenser Containment Sensogs), Model: Shear Valve(s). Shear Volve(s), Dispenser Containment Floats)and Chain(s). Ll Dispenser Containment Float(s)and Chain(s). G. Certification "if the facility contains more tanks or dispensers,copy this form,include information for every tank and dispenser at the facility. 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 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; XAlarm history report PRINTED NAME-WILLARD DEAN LUKEHART JR SIGNATURE: OR COMPANY: Tainknoloav PHONE NO: _(_8001800.4633 page 7 of 3 Based on CA form dated 03/01