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JAN-20-2012 11:09 Ser ice Station Systems 488 938 8888 P.07 Monitoring System e lc Y 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, Cal fornia Code.of Regulatinm This form trust be.:used to document testing and servicing of monitoring equipment. .9 separate ccrtitication or report rnuct he prepared for each mnnitoring,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 system within 3()days of test date. A. General Information Facility Name:Tracy Blvd Shell&Mini Mart Bldg. No,: Site Address: 3725 N.Tracy Blvd. City: Tracy, CA Zip: 95376 Facility Contact Person: Manager Contact Phone No.: (209)835-7608 Makc/Modcl of Monitoring System: Beaudreau 522T Date ofTesting/Servicing: 1/5/12 3. Inventory of Equipment Tested/Certiftcd Check the appropriate boxes to indicate specific equipment inspected/serviced: Tanis ID;01-Rego Tank iD• 02-Plus ❑ in-Tank Gauging Probe. Modal: ❑ in-Tank Gauging Probe. Model: C3 Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor, Model; ❑ Piping Sump\Trench Sensor(s), Model: (3 Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sancor(s), Model; ❑ Fill Sump Sensor(s). Model; Mechanical Line Leak Detector. Model: [3 Madianical Line Leak Detector, Modol: ❑ Electronic Line Leak Detector, Model; ❑ Electronic Line Leak Detector. Model: (3 Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-l..avel Sensor, Modal; ❑ Other(specify equipment type and model in Section E on Page 2). [3 Other(specify equipment type and model in Section E on Page 2). Tank We 034Prem Tank 1(D. 04-Diesel Q In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model;. .._ _ _ Q Annular Space or Vault Sensor, Model: ❑ Piping Sump\Trench Sensor(s), MOW; ❑ Piping Sump\'french Sensor(s). Model ❑ Fill Sump Sensor(s), Model; ❑ Fill Sump Sensor(s). Model; t7 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: C) Electronic Line Leask Detector. Model: (3 Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-level Sensor, Model; ❑ 'T'ank Overfill\fligh-LCvel Sensor, Model; [a Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Pago 2). ID-. 01-02 Dispenser.10. 03.64 [Dispensor n Dispenser Containment Sensor(s). Model: Beaudreau S10 1$I Dispenser Containment Sensor(s). Model: Beaudreau 310 ® Sherr Valve(s), H Shear Valve(s). p Dispenser Containment Float(s)and Chain(s), ❑ Dispenser Containment Float(s)and Chain(s), Dispenser ID: 05-66 Dispenser I.D• 07.08 11 Dispenser Containment Sensor(s). Madel: Beaudreau 510 Dispenser Containment Sensor(s). Model: Beaudesau 510 g Shear Valve(s). Shear Valve(s). (3 Dispenser Containment bloat(s)and Chain(s), D Dispenser Containment Float(s)and Chain(s). Dispenser ID• 09-10 Dispenser ID' 11*12 Dispenser Containment Sensor(s), Model: Beaudmau57o X Dispenser Containment Sensor(s). Model: Beaudreau 510 * Shear Valve(s). ® Shear Valve(s), ❑ Dispenses Containment Float(s)and Chairi(s), ❑ Dispenser Containment Flown(s)and Chain(s), 'if the f tcilily 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 tate manufacturer's guidelines. Attached to this Certification is information(e,g,manufactures'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capabte of generating such reports,I have also attached a copy of the; (check sH dratappfy). (3 System set-up Q Alarm history report Technician Name(print): Randy Wilkerson Signature: &L- Mfg,Cert.#.: ICC# 5258564-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: 408 971-2445 Testing Company Address: 680 Quinn Ave.,San Jose, CA 95112 Date of Testing/Servicing: 1/5/12