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MONITORING SYSTEM CERTIFICATION ec(2� For Use By All Jurisdictions Within the State of California `°°'6"e`CaMP""CE Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California H D This form must be used to document testing and servicing of monitoring equipment. A separate certification or ren r r ac monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tanksye o / a;or. 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 ENVIRONMENTAL Facility Name: Shell Bid .H DEPARTMENT Site Address: 16500 S. Harlan Road City: Lathrop,CA Zip: 95330 Facility Contact Person: Chris Contact Phone No.: (209) 983-0381 Make/Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servicing: 02/28/2017 B. Inventory of Equipment Tested/Certified Check t e appropriate boxes to indicates ecific equipment ins ected/serviced: Tank ID: #1 Regular 12000 Gal Tank ID: #2 Premium 12000 Gal Z In-Tank Gauging Probe. Model: MAGA ®In-Tank Gauging Probe. Model: MAGA ®Annular Space or Vault Sensor. Model: 794380-409 ®Annular Space or Vault Sensor. Model: 794380-409 ®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 Z Mechanical Line Leak Detector, Model: Vaporless 99LD2000 ®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 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 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z 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 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Float(s)and Chain(s). Z 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): Z System set-up Z Alarm history report Technician Name(print): Nik Zagorov Signature: N ra/ 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 1394, Lafayette,CA 94549 Date of Testing/Servicing: 02/28/2017 Page 1 of 4 Rev(2/08)