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.d MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Calofmi Authority Chapter 6.7, Health and Safety Code; Chapter 16, Division a 23, California Code of Regulations This Form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is insalled at the facility, a separate certification or report must be prepared for each monitring 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 tot a local agency regulating UST systems within 30 days of test date. Instructions are printed on the back page. A. General Information Facility Name: ULTRAMAR #502 Site Address: 35 N. CHEROKEE LANE Facilty Contact Person: MGR - GRACE Make/Model of Monitoring System: B.Inventory of Equipment Tested/Certified City: LODI Contact Phone No: 369-1525 Date of Testing/Service: 04/12/2001 Word Order Number: 2216330 Check the appropriate boxes to Indicate specific equipment inspected/serviced CA ZIP: 95240 Tank ID: 1 Tank ID: 2 In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 4000 Annular Space or Vault Sensor. Model: 4000 Piping Sump/Trench Sensor(s). Model: 2592 Piping Sump/Trench Sensor(s). Model: 2592 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: LD2000 71 Mechanical Line Leak Detector. Model: LD2000 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: ShearValve(s). Shear Valve(s). Dispenser Containment Float(s) and Chains(s). 71 Dispenser Containment Float(s) and Chains(s). Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). an : 3 1 an . In -Tank Gauging Probe. Model: 7 In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 4000 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 2592 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: LD2000 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: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chains(s). Dispenser Containment Float(s) and Chains(s). Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). C. Certification I certify that the equipment idendfled in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this certification is information (e.g manufacturer's checklists) necessary to verify that this information is confect. and a Site Plan showing the layout of monitoring equipment For any equipment capable of generating such reports, 1 have also attached a copy of the (Check all that apply): System set-up report Alarm history report El PRINTED NAME: WILLARD DEAN SIGNATURE: / COMPANY: Tanknology PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 05/00