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MONIT4)RING SYSTEM CETII TION 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 testingand servicingofp ��i� rate certification or report must be re ared for each monitoring_ system control panel by the techician who perfformsH�A-edt'dt tht3 must provided to he tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information JAN 2 1 2009 Facility Name: SHELL ENVIRONMENT HEALTH Bldg. No.: RP 41T_ tcros w-r-C Site Address: 341 E. MAIN PEIMi ' City:` IPON Zip: 95366 Facility Contact Person: ANGLE Make/Model of Monitoring System: SIMPLICITY B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eouipment inspected/serviced: Contact Phone No.: (209) 559-4544 Date of Testing/Servicing: 1/14/2009 Tank ID: 87 Tank ID: 91 ® In -Tank Gauging Probe. Model: MAGA ® In -Tank Gauging Probe. Model: MAGA ® Annular Space or Vault Sensor. Model: BRINE ® Annular Space or Vault Sensor. Model: BRINE N 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: N Electronic Line Leak Detector. Model: PLLD N Electronic Line Leak Detector. Model: PLLD ❑ 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: 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 N Dispenser Containment Sensor(s). Model: 321 N Dispenser Containment Sensor(s). Model: 321 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Flcp'(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 N Dispenser Containment Sensor(s). Model: 321 N Dispenser Containment Sensor(s). Model: 321 N Shear Valve(s). N 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/ser ced 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 histo y report Technician Name (print): Heath A MCEver Signature: Certification No.: A27562 License. No.. 5236756 -UT Testing Company Name: SST -Service Station Testi Testing Company Address: PO Box 31465 Page 1 of 3 Phone No.: L209) 465-5577 _ Date of Testing/Servicing: 1/14/2009 Rev (2/08)