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MONITOMNG SYSTEM CERTIFICAaIUN Fnr Us All Jurisdictions Within the State of CaliJor Aalix�rity Cited: Chapter 6.7, Heath and Safety Cade;Chapter 16, Division 3, Title 23, t alifirrnia Cnde of Regula(iuns This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be re ed 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 FacilityName: SHELL OIL COMPANY Service Station No.: Site Address: 3515 NAVY DRIVE City: STOCKTON Zip: 95203 Facility Contact Person: TOM EIKEMEIRER Contact Phone No.: 916-997-0054 Make/Model of Monitoring System: RONAN X76S Date of Testing/Service: 11/13/06 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins cted/serviced: Tank ID: RECLAIM TANK Tank ID: ❑In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: - ®Annular Space or Vault Sensor: Model: LS-7 []Annular Space or Vault Sensor Model: _ ❑Piping Sump/Trench Sensor(s): Model: ❑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 Ovefill/High-level Sensor: Model: _ ❑Other,Specify ui . and model in Section E on Page 2 ❑Other,Specify ui .type and model in Section E on Page 2 Tank ID: Tank ID: [I In-Tank Gauging Probe: Model: ❑ln-Tank Gauging Probe: Model: ❑Annular Space or Vault Sensor: Model: ❑Annular Space or Vault Sensor Model: C1 Piping Sump/Trench Sensor(s): Model: []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: ❑Ocher,Specify ui , type and model in Section E on page 2 ClOther,Specify ui .t and model in Section E on Pae 2 Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dia enser Containment Float s)and Chains nDispenser Containment Floats and Chainw. Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). Cl Shear Valve(s). ❑Lha user Containment Floats and Chains []Dispenser Containment Float(s)and Chains) Dispenser ID: Dispenser ID: []Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). oDisE2nser Containment Float s and Chains DDIspenser Containment Float(s)and Chain(s) *If the facility contains more tanks or dispensers,copy this form. Include information fur every tank and dispenser at this 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 Plot Plan showing the layout of monitoring equipm t. For any equipme t capable of een�erating such reports,I have also attached a copy of the report; (check all that apply): l9 Jystem set-up 'tory= N!A Technician Name(Print): _MICHAEL L. STRAW.N,11 Signature: Certification No.: 76061001 License No.: 88 098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222 D_ I rl rami 8001 ] 'IV,LNHM0HIAN3 ,LIV1 TTOT13989T0 YVd 96:LT 9002/6T/TT