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P'a WiP Monitoring System Equi ment Certific IVED IP P"or Use 13y,411,1urisdictions Within The State of California FEB 2 7 2015 A whorily Cited: Chapter 6 7, Health and Safety Cocic; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separati: c rtifigawy NTAL prepared for each monitoring system control panel by the technician who performs the work. A copy of thiM-r%'YL1sfb9$?dRffiW' 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: Tracy Blvd Shell & Mini Mart - Bldg. No.: Site Address: 3'7'25 N. Tracy Blvd. City: Traciy, CA, Zip: 96376 Facility Contact Person: Manager Contact Phone No.: (209) 835-7608 Make/Model of Monitoring System: Beaudreau 522T Date of Testing/Servicing: 1/29/15 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID..01-Renu Tank 1D• 02 -Pius [I In - Tank Gauging Probe. Model:� [] In - Tank Gauging Probe. Model: C] Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: 0 Piping Sump \ Trench Sensor (s), Model: [] Piping Surnp \ Trench Sensor (s). Model: [I Fill Sump Sensor (s). ModeL C] Fill Sump Sensor (s) Model: C] Mechanical Line Leak Detector, Model: 0 Mechanical Line Leak Detector, Model: L] Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill \ High -Level Sensor. Model: 0 Tank Overfill 1 High -Levet Sensor. Model: 0 Other ( specify equipment type and model in Section E on Page 4 0 Other (specify equipment type and model in Section r on Page 2). Tank In! 03 -Prom Tank ID! 04 -Diesel 0 In - Tank Gauging Probe. Model: 0 In -Tank Gauging Probe. Model: [] Annular Space or Vault Sensor. Model 0 Annular Space or Vault Sensor. Model: Cl Piping Sump \ Trench Sensor (s). Model, [I Piping Sump i Trench Sensor (s). Model: 0 Fill Sump Sensor (s). Model: 0 Fill Sump Sensor (s). Model: [] Mechanical Line Leak Detector, Model [] Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: 0 Tank Overfill \ High -Level Sensor, Model: ❑ Tank Overfill \ High -Level Sensor. Model: 0 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 ID. 01-02 Dispenser 10! 03-04 Dispenser Containment Sensor (s), Model: Beaudreau 406 --- . ...... . Dispenser Containment Sensor (s), Model:- seawdreau,100 Shear Valve (5). Shear Valve (s). 171 Dispenser Containment Float (s) and Chain (s), 0 Dispenser Containment Float (s) and Chain (s). Dispenser IDL 06-06 Dispenser I ,• 07-08 (A Dispenser Containment Sensor (s). Moduli Besudmau 406 (M Dispenser Containment Sensor (s), Model' Seaudreau 406 Ull Shear Valve s), IS Shear Valve (s), 0 Dispenser Containment Float (s) and Chain (s). 0 Dispenser Containment Float (s) and Chain (s). Dispenser ID: 09-10 Dispenser ID; 11-12 N Dispenser Containment Sensor (s), Model Beaudreau,toli W Dispenser Containment Sensor (s). Model: Beaudreau-ws H Shear Valve (s), H Shear Valve (s). 0 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 inspeeted/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information (e.g. manufactures' checklists ) necessary 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; (check ail that apply): 0 System set-up 0 Alarm history report Technician Name (print)Isra I Santillan Signature - Mfg. CertA: ICC# 8057671 -UT License. No,: 485184 Testing Company Name: Service Station Systems_ Phone No.: (408) 971-2446 Testing Company Address* 680 Quinn Ave., San Jose, CA 55112 Date of Testing/Servicing: 1/29/15