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MONITORING SYSTEM CERTIFIATION 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: 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: 10/16/06 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/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: LS-3 []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 Irak Detector Model: []Tank Overfill/High-level Sensor: Model: []Tank Overfill/High-level Sensor: Model: []Other,S ecif a ui .ty2e and model in Section E on Page 2 ❑Other,Sgmify equip.t e and model in Section E on Pa e 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 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 Overfill/High-level Sensor: Model: ❑Other,Specify a ui a and model in Section E on Pae 2 ❑Other,Specify equip.t e and model in Section E on Page 2 Dispenser ID: Dispenser ID: []Dispenser Containment Sensors: Model: []Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑Shear Valve(s). []Dispenser Containment Float(s)and Chain(s) ❑Dis enser Containment Float(s)and Chain(s) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s) ❑Dis enser Containment Float(s)and Chain(s) Dispenser ID: Dispenser ID: []Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s) ❑Dis enser 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 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 equipment. For any equipment capable of genera in s •1 ports, ve-alflo�, attached a copy of the report;(check all that apply): ❑ System set-up ❑ Alarm history r Technician Name(Print): MICHAEL L.STRAWN,H Signature: Certification No.: 76061001 License No.: 588 098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560- Page 1 of 3 03/01 Monitoring System Certification