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MONIT NG SYSTEM CERTIFI TION se By All Jurisdictions Within the State of CalifomI Authority Cited: Chapter 6.7, He h and Safety Code; Chapter 16, Division 3 Title 23, a ifomia 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 installed at the facility, 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 # 136186 Site Address: 3725 N. TRACY BLVD Facility Contact Person: MANAGER Make/Model of Monitoring System: SIMPLICITY B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced City: TRACY CA Zip: 95376 Contact Phone No: 835-7608 Date of Testing/Service: 02/20/2008 Work Order Number: 2254916 Tank ID: T1 87 Tank ID: T2 89 %f In -Tank Gauging Probe. Model: MAG X In -Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: BRINE N Annular Space or Vault Sensor. Model: BRINE X Piping Sump/Trench Sensor(s). Model: 352 MV Piping Sump/Trench Sensor(s). Model: 352 X Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: PLLD X Electronic Line Leak Detector. Model: PLLD 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: T391 Tank ID: T4 DSL 71 In -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: BRINE Annular Space or Vault Sensor. Model: BRINE X Piping Sumprrrench Sensor(s). Model: 352 X Piping Sumprrrench Sensor(s). Model: 352 X Fill Sump Sensor(s). Model: 208 X Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: PLLD X Electronic Line Leak Detector. Model: PLLD 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 : 1/2 Dispenser ID: 3/4 X❑ Dispenser Containment Sensor(s) Model: BEI 406 X Dispenser Containment Sensor(s) Model: BEI 406 XD Shear Valve(s). X 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 XO Dispenser Containment Sensor(s) Model: BEI 406X Dispenser Containment Sensor(s). Model: BEI 406 X❑ Shear Valve(s). 711 Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 X❑ Dispenser Containment Sensor(s) Model: BEI 406 X Dispenser Containment Sensor(s). Model: BEI 406 FX Shear Valve(s). X Shear Valve(s). 10 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 Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the (Check all that apply): ❑ System set-up X❑ Alarm history report Technician Name (print): SCOTT HOLMAN Signature: ��E✓L., Certification No.: 8001467 -UT License. No.: Testing Company Name:Tanknology Phone No.: (800) 800-4633 Site Address: 8501 N. Mopac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 02/20/2008 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01