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APR -04-2006 09:15 Service Station Systems 408 938 8888 P.03 Monfton® gt Sysirem •tern • a pmeiat ticaon For Use By All Jurisdictions Within The State of California Authority Cited., Chapter 6.7, Wealth 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 2r report must be RLgWed 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 system within 30 days of test date_ A. General Information Facility Name: Trael Blvd Shell & Mini Mart -- Bldg_ No.: Site Address: 3725,N. Tracy Blvd. a 1.205 City: Tram, CA Zip: 85376 Facility Contact Person: Mack Contact Phone No.: X09 835-7608 Make/Model of Monitoring System: WR Sim Ilei Date of Testing/Servicing: 3/21/06 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspectediserviced, Tank ID° Tank IDi n In - Tank Gauging Probe, Model; ? _ __. _ .. ❑ In - Tank Gauging Probe. Model: 7 ❑ Annular Space or Vault Sensor. Model: ? ❑ Annular Space or Vault Sensor. Model: 7 ❑ Piping Sump 1 Trench Sensor (s). Model: ? ❑ Piping Sump 1 Trench Sensor (s). Model: Q Fill Sump Sensor (s). Model: _L_ ❑ Fill Sump Sensor (s). Model: 7 ❑ Mechanical Line Leak Detector, Model: ? ❑ Mechanical Line Leak Detector. Model; 7 ❑ Electronic Line Leak Detector. Model: 7 q Electronic Line Leak Detector, Model: ? ❑ Tank Overfill \ hligh-Level Sensor. Model: ? ❑ Tank Overfill \ High -Level Sensor. Model 9 ___._._.__....... ❑ 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: p ❑ In - Tank Gauging Probe. Model: 7 ❑ Annular Space or Vault Sensor, Model: ? ❑ Annular Space or Vault Sensor. Model: 7 ❑ Piping Sump \ Trench Sensor (s). Model: ? ❑ Piping Sump \ Trench Sensor (s). Model: ? ❑ Fill Sump Sensor (s). Modcl; ? ❑ Fill Sump Sensor (s). Model; ? ❑ Mechanical Line Leak Detector, Model; ? ❑ Mechanical Line Leak Detector, Model; ? ❑ Electronic Linc Leak Detector. Model: _?_____. __ .. ❑ Electronic Linc Leak Detector, Model: ? ______................ ❑ Tank Overfill \ High -Level Sensor. Model: 7 ❑ Tank Overfill \ Iligh-Level Sensor. Model: _._%_.__.._....... . 0 Other ( specify equipment typo and model in Section E on Page 2). Q Other ( specify equipment type and model in Section E on Page 2). Dispenser ° 13-14 Dispenser ID° is -is ® Dispenser Containment Sensor (s). Model: Beaudreau 406 tj Dispcnscr Containment Sensor (s). Model: Bvaudroau 406 11 Shear Valve (s), N Shear valve (s), E3 Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser W Dispenser ID° 17 Dispenser Containment Sensor (s). Model: 7 ❑ Dispenser Containment Sensor (s), Model; ? ❑ Shear Valve (s). p Shear Valve (s), ❑ Dispenscr Containment Float (s) and Chain (s), ❑ Dispenser Containment Float (s) and Chain (s). Dispenser lD° Dispenser ° ❑ 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 r I certify that the equipment idendfled in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information (e.g. manufactures' checklists ) necessary to verily that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generafiag such reports, I have also attached a copy of the; (check all that apply): p System set-up 0 Alarm history report Technician Name (print): Steve Parmnt®r Signature: = Mfg. Cert.#. 008.05-1621 icc# 5261254 -UT License. No.: 485184 Testing Company Name: Ser- Sta. PYS- Phone No.; (4081971-2445 Site Address: 3725 N. Tracy Blvd. a 1-205 Date of Testing/Servlcing: 3121106