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jfj�-J-aIVEU Monitoring System Equipment Certe For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 7, Health and Safety Code,- Chapter 16, Division 3, Title 23, Cal Code f QAf U 6 015 This form must be used to document testing and servicing of monitoring equipment. A.-separate.certi I WO Oft" prepared for each monitoring system control panel by the technician who performs the work. A copy of thil4blIpT"Oft" W 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: 3725 N. Tracy Blvd. City: Tracy, CA — Zip: 95376 Facility Contact Person: Manager Contact Phone No.: (209) 835-7608 Make/Model of Monitoring System: Beaudreau 522T Date of Testing/Servicing: 1129116 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced: Tank ID: Tank E) iD: In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor, Model! 0 Piping Sump \ french sensor (s). Model: ❑ Piping Sump k Trench Senior (s). Model: 0 Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: 0 Mechanical Line Leak Detector, Model: E) Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector, Model: 0 Tank Overfill \ High -Level Sensor, Model: E) Tank Overfill\ High -Level Sensor. Model: [3 Other ( specify equipment type and model in Section C on Page 2). 0 Other (specify equipment type and model in Section E on Page 2), Tankl Tank 0 1111: In -Tank Gauging Probe, Model: C] In - Tank Gauging Probe, Model: [] Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: 0 Piping Sump N Trench Sensor (s). Model: 0 Piping Sump k Trench Sensor (s), Model: ❑ Fill Sump Sensor (s). Model: 0 Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: 0 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: D Other ( specify equipment type and model in Section E on Page 2). 0 Other ( specify equipment type and model in Section E on Page 2). Dispenser ID, 13*14 Dispenser ID- 16-16 0 Dispenser Containment Sensor (s). Model: 9eaudreau _406 Dispenser Containment Sensor (s). Model: Seaudreau,106 Shear Valve (s). Shear Valve (s), ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s), Dispenser 1D., Dispenser 0 ID; Dispenser Containment Sensor (s). Model: 0 Dispenser Containment Sensor (s), Model: 0 Shear Valve (s). ❑ Shear Valve (s), 0 Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser I U Dispenser ID: [3 Dispenser Containment Sensor (s), Model: [I Dispenser Containment Sensor (s). Model: E) Shear Valve (s), ❑ 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 inspected/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; (cheek all that apply): (3 System set-up 0 Alarm history report Technician Name (print)! Israel Santillan Signature: Mfg. Cert.#.: icc# 8067671 -UT License. No.: 486184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2446 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 1129/16