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1 Appendix VI W ECJ I �' FIE, (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available athttp://www.swrb.ca.eov) ONITORING SYSTEM CERTIFICATION FEB21 552009 For Use By All Jurisdictions Within the State of California(� 1—E R " LHEAt TH. Authority Cited. Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Co h" g$OM a/ u,.,10ES 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 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 FOOD MART Site Address: 2320 N. EL DORADO STREET Facility Contact Person: Bob Lutz Make/Model of Monitoring System: TLS -350 B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicates ecific a ui ment inspected/serviced: Bldg. No.: City: STOCKTON Zip 95204 Contact Phone No.: 209-483-7671 Date of Testing/Servicing: February 23, 2009 Tank ID: #1 PREMIUM Tank ID: DIESEL ❑X In -Tank Gauging Probe. Model: Mag Probe ® In -Tank Gauging Probe. Model: Mag Probe (x) Annular Space or Vault Sensor. Model. Duel F h at - 302 Cu Annular Space o Vault Sensor. Mode:: Duel Floa` - 302 (x)Piping Sump /Trench Sensor(s). Model: Duel High Vapor- 352 ® Piping Sump / Trench Sensor(s). Model: Duel High Vapor- 352 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ( ) Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: IM Electronic Line Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other(specify equipment a and model in Section Eon Pae 2). ❑ Others eci equipment a and model in Section E on Pae 2). Tank ID: #2 REGULAR Tank ID: ❑ In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model: Mag Probe ® Annular Space or Vault Sensor. Model: Duel Float - 302 ❑ Annular Space or Vault Sensor. Model: ❑x Piping Sump / Trench Sensor(s). Model: Duel High Vapor- 352 ❑ 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: El Electronic Line Leak Detector. Model: PLLD ❑ Electronic Line Leak Detector. Model: _ ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Others eci !3!iment !Xpe and model in Section E on Pae 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1 & 3 Dispenser ID: 6 & 8 () Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). (x)Dispenser Containment Float(s) and Chain(s). Bravo ® Dispenser Containment Float(s) and Chain(s). Bravo Dispenser ID: 2 & 4 Dispenser ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). ❑x Dispenser Containment Float(s) and Chain(s). Bravo ❑ Dispenser Containment Float(s) and Chain(s). Dispenser 11..1: 5 .& 7 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: C] iiispenser Corttrainment S,,iisor(s). b1odel: _ Shear Valve(s). ❑ Shear Valve(s). ®Dispenser Containment Floats and Chains . Bravo ❑ 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): Eric Molgaard Signature: Eric NoCgaard Certification No.: V/R A27995 ICC Tech 525020OUT License No.: 309105 "Testing Company Name: STOCKTON SERVICE STATION EQUIPMENT CO. INC. Phone No 209-464-8333 Testing Company Address: 808 N. Union Street, Stockton, CA 95205.4152 Date of Testing/Servicing: February 23, 2009 Monitoring System Certification Page 1 of 4 12/07