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MONIT NG SYSTEM CERTIFI ION ; 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 monitoring 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: 76 (GREWALS) Bldg.No.: Site Address: 4100 E. FREMONT City: STOCKTON Zip: 95205 Facility Contact Person:. SIGNH Contact Phone No.: (2 9) Make/Model of Monitoring System: GILBARCO EMC Date of Testing/Servicing: 8/5/2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: 87 Tank ID: 91 ®In-Tank Gauging Probe. Model: MAG-1 ®In-Tank Gauging Probe. Model: MAG-1 ®Annular Space or Vault Sensor. Model: 420 ®Annular Space or Vault Sensor. Model: 420 ®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: 420 ❑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: 1-2 Dispenser ID: 3-4 ®Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containment Sensor(s). Model: 208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ®Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containment Sensor(s). Model: 208 ®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). *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 Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): ❑System set-up ®Alarm his report Technician Name(print): HEATH MCEVER Signature: Z<�� _ Certification No.: A27562 License.No.: 36756-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: 8/5/2009 Page 1 of 3