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t MONITORING SYSTEM CERTIFICATION ece� For Use By All Jurisdictions Within the State of California E£L`C.E. 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 systems within 30 days of test date. A. General Information Facility Name: Shell Bldg.No.: Site Address: 16500 S. Harlan Road City: Lathrop, CA Zip: 95330 Facility Contact Person: Nick Arbabian Contact Phone No.: (209) 983-0381 Make/Model of Monitoring System:Veeder Root TLS 350 Date of Testing/Servicing: 02/12/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: #1 Regular 12000 Gal Tank ID: #2 Premium 12000 Gal E In-Tank Gauging Probe. Model: MAGA ®In-Tank Gauging Probe. Model: MAGA E Annular Space or Vault Sensor. Model: 794380-407 ®Annular Space or Vault Sensor. Model: 794380-407 E Piping Sump/Trench Sensor(s). Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: Vaporless 99LD2000 E Mechanical Line Leak Detector. Model: Vaporless 99LD2000 ❑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). Tank ID: Tank Ill: ❑ 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 Ill: 3-4 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). E Dispenser Containment Float(s)and Chain(s). E Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). E Dispenser Containment Float(s)and Chain(s). E 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 history report Technician Name(print): Nikola Zagorov Signature: �G._..a.lp fit/ Certification No.: Veeder Root Level 4#A32784 License.No.: 958763 A Testing Company Name: ECO-CHEK Compliance, Inc. Phone No.:(888) 500-CHEK Testing Company Address: P.O. Box 77194 San Francisco CA 94107 Date of Testing/Servicing: 02/12/2014 Page 1 of Rev(2/08)