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MONITQWNG SYSTEM CETIFI TION <br /> se By All Jurisdictions Within the State of Califom <br /> Authority Cited:Chapter 6.7,Hea h and Safety Code;Chapter 16,Division 3 Title 23, ifomia Code of Regulations <br /> 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 facility,a separate <br /> 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 <br /> 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. <br /> A.General Information <br /> Facility Name: ULTRAMAR 641 City: STOCKTON CA Zip:95210 <br /> Site Address: 1210 E.HAMMER LANE Contact Phone No: 477-3111 <br /> @ WEST LANE Date of Testing/Service: 08/02/2004 <br /> Facility Contact Person: MGR-VALERIE <br /> Make/Model of Monitoring System:GILBARCO EMC Work Order Number: 2231836 <br /> B.Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicate specific equipment inspected/serviced <br /> Tank ID: 87 Tank ID: 89 <br /> X in-Tank Gauging Probe. Model: MAG PROBE X In-Tank Gauging Probe. Model: MAG PROBE <br /> X Annular Space or Vault Sensor. Model: 420 E Annular Space or Vault Sensor. Model: 420 <br /> )( Piping Sump/Trench Sensor(s). Model: 208 Piping p g Sum plTrench Sensor(s). Model: 208 <br /> X Fill Sump Sensor(s). Model: 208 <br /> Fill Sump Sensor(s). Model: 208 <br /> Mechanical Line Leak Detector. Model: FX1V FX1V <br /> Mechanical Line Leak Detector. Model: <br /> Electronic Line Leak Detector. Model: Electronic Line Leak Detecto, Madel: <br /> Tank Overfill/High-Level Sensor. Model: ELECTRONIC/KLAXON X Tank OverfilItHigh-Level Sensor. Model: ELECTRONIC/KLAXON <br /> Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). <br /> ank ID: 91 Tank ID: <br /> -xj In-Tank Gauging Probe. Model: MAG PROBE In-Tank Gauging Probe. Model: <br /> X Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model: <br /> X Piping Sum pll Tench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: <br /> X Fill Sump Sensor(s). Model: 20$ DFill Sump Sensor(s). Model: <br /> XMechanical Line Leak Detector. Model: FX1 V Mechanical Line Leak Detector. Madel: <br /> Electronic Line Leak Detector. 1: Electronic Line Leak Detector. el: <br /> X Tank Overfill/High-Level Sensor. Model: ELECTRONIC/KLAXON Tank Overfill/High-Level Sensor. Madel: <br /> Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). <br /> Dispenser : 1/2 DispenserID: 3/4 <br /> Dispenser Containment Sensor(s) Model: 7 Dispenser Containment Sensor(s) Model: <br /> =X1 Shear Valve(s). -X-1 Shear Valve(s) <br /> ®Dispenser Containment Float(s)and Chain(s). -X-1 Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: 5/6 Dispenser ID: 7/8 <br /> Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: <br /> X Shear Valve(s). 71 Shear Valve(s). <br /> F1 Dispenser Containment Float(s)and Chain(s). 71 Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: <br /> Shear Valve(s). ShearValve(s). <br /> ElDispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). <br /> "If the facility contains more tanks or dispensers,copy this form.Include information for every tank and dispenser at the facility. <br /> C. Certification <br /> I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'guidelines. <br /> Attached to this certification is information(e.g manufacturers'checklists)necessary to verify that this information is correct. <br /> and a Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached <br /> a copy of the(Check all that apply): X❑System set-up X❑Alarm history report <br /> Technician Name(print): HEATH MCEVER Signature: <br /> Certification No.: License.No.: <br /> Testing Company Name:Tanknology Phone No.: (800)800-4633 <br /> Site Address: 8900 Shoal Creek,Bldg.200 Austin,TX 78757 Date of Tesfing/Servicing: 08/02/2004 <br /> Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01 <br />