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Monitori g SystemEquipment Certification 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 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: Tanya Contact Phone No.: (209) 835-7608 Make/Model of Monitoring System: V!R Simplicity Date of Testing/Servicing: 1129113 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 01-Regu Tank IDL -02 -Plus ❑ In - Tank Gauging Probe. Model: VR 847390-107 ❑ In - Tank Gauging Probe. Model: VR 847380-107 IN Annular Space or Vault Sensor. Model: VR 794380-301 IN Annular Space or Vault Sensor. Model: VR 794380301 10 Piping Sump \ Trench Sensor (s). Model: VR 784890-208 ® Piping Sump \ Trench Sensor (s). Model: VR 794380-208 IN Fill Sump Sensor (s). Model: VR 794380-208 N Fill Sump Sensor (s). Model: VR 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: IN Electronic Line Leak Detector. Model: VR series 8484 11 Electronic Line Leak Detector. Model: VR Series 8484 ❑ 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: 03 -Prem Tank 1]11_q4 -Diesel ❑ In - Tank Gauging Probe. Model: VR 847390-107 ❑ In - Tank Gauging Probe. Model: VR 847390-107 ® Annular Space or Vault Sensor. Model: VR 784380-301 ® Annular Space or Vault Sensor. Model: VR 794380-301 ® Piping Sump \ Trench Sensor (s). Model: VR 794380-208 N Piping Sump \ Trench Sensor (s). Model: VR 794380-200 N Fill Sump Sensor (s). Model: VR 794380.208 ig Fill Sump Sensor (s). Model: VR 794399-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. — Model: C1 Electronic Line Leak Detector. Model: VR series 8484 ® Electronic Line Leak Detector. Model: VR Series 8484 ❑ 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 ID: Dispenser ID• ❑ 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). Dispenser ID• Dispenser ID• ❑ 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). Dispenser ID_:___Dispenser ID• ❑ 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 - 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 Piot 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 thataPPIO. ❑ System set-up ❑ Alarm history report Technician Name (print): Steve Parmenter Signature: , Mfg. Cert.#.: A28780 ICC# 5311561 -UT License. No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 1129113