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MONTIAUNG SYSTEM CETIFIC 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 §ZM%e certification or report merit be prepared for each monitoring system control panel by the technician who perforans 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 agenq regulating UST systems within 30 days of test date. A. General Information Facility Name: Valero Bldg. No.: Site Address: 1605 S El Dorado City: Stockton Zip: 95206 Facility Contact Person: Mr Angle Contact Phone No.: (209) 939-1906 Make/Model of Monitoring System: EMC Date of Testing/Servicing: 51412009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate a iFic mui cut inn cted/sorviced: Tank ID: T-1 UNL Tank ID: SUpr9 m9 ® In -Tank Gauging Probe. Mom: PA0265130200 ® in -Tank Gauging Probe. Model: PA0265130200 ® Annular Space or Vault Sensor. Model: '794390420 ❑ Amain Space or Vault Sensor. Model: N Piping Sump / Trench Sensor(s). Model: PA00302000 ® Piping Sump / Trench Sensor(s). Model: PA00302000 ❑ Fill Sump Seusor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Lim Leak Detector. Model: LO -2000 ® Mechanical Lim Leak Detector. Model: LD -2000 ❑ Elechonic Line Leak Detector. Model: ❑ Electronic Lim Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sen". 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• Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Scow. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench s). Model: ❑ Fill Sum s). ❑ Fill S s). ❑ Mechanical Line Leak Deteaw. Model- ❑ mechaniew Linn Leak Deftoor, Model: Electronic Lice Leak DetWor. Model: ❑ Electronic Line Leak Dmmr. Model: ❑ Tank Overfill / Hi ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ 08nn (specify Nutmatit type and model is Section Ear Pap 2). Dispenser ID' 112 Dispenser ID: 3/4 ® Dispenser Sensor(s). Model: Stan® Alone- 330212-001 ® Containment Sensor(s). Model: Steffe Alone- 3302121 ® Shear Valve(s). ® Shear Valvo(s). ® Dispenses Containment Float(s) and Chars). ® Dispenser Containment Float(s) and Cham(s). Dispenser ID: 516 Dispenser ID: ® Containment Seosor(s). Model: Stand Alone- 330212-001 ® Scesor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ® Dispenser Contamment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chars). Dispenser ID' Dispenser ID: ❑ Sensor(s). Model: ❑ Dispenser Containment Seasor(s). Model: ❑ Shear Valve(s). ❑ Shear Vaive(s). ❑ Dispenser Containment Float(s) and Chars). ❑ Dispenser Containment Floats) and C liars). *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and d6penser 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) neemary to verify that this information is correct and a Plot 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): R9Sy m set p arm history report Technician Name Gavin Williams Signature: Certification No.: 8016288 -UT License. No.: 856771 Testing Company Name: HMC - Hendemon Maintenance Company Phone No.: ( ) -7573 Site Address: Date of Testing/Servicing: SM12009 Page 1 of 3