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MONII*RING SYSTEM CERTIFIWTION RECEIVED 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 Reg�,IAWI 5 2013 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 VNVM0WMatgA EALTH The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. PERWAVSERVICES A. General Information Facility Name: RIPON SHELL Bldg.No.: Site Address: 341 E. MAIN ST City: RIPON Zip: 95366 Facility Contact Person: MGR Contact Phone No.: ( ) Make/Model of Monitoring System: SIMPLICITY Date of Testing/Servicing: 1/17/2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: REGULAR Tank ID: PREMIUM ❑In-Tank Gauging Probe. Model: _ ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 302 ®Annular Space or Vault Sensor. Model: 302 ' ®Piping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: E Electronic Line Leak Detector. Model: VR 8484 E Electronic Line Leak Detector. Model: VR 8484 ❑Tank Overfill/High-Level Sensor. Model: FLAPPER E Tank Overfill/High-Level Sensor. Model: FLAPPER ❑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: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑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: ❑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: 1/2 Dispenser ID: 3/4 E Dispenser Containment Sensor(s). Model: STAND ALONE-001 E Dispenser Containment Sensor(s). Model: STAND ALONE-001 ❑Shear Valve(s). ❑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 E Dispenser Containment Sensor(s). Model: STAND ALONE-001 E Dispenser Containment Sensor(s). Model: STAND ALONE-001 ❑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 manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' 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 report;(check all that apply): ® System set-up ® Alarm his py repo Technician Name(print): Charles Ferrueci 303 `/t/5 Signature: Certification No.: B37513 License.No.: 962520 Testing Company Name: Henemon aintenence Phone No.: (209) 465-5577 Testing Company Address: PO Box 31465 Stockton, Ca 95213 Date of Testing/Servicing: 1/17/2013 Page 1 of 3 Rev(2/08)