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Monitoring System Equipment Certification For Use By.411,1urisdictions Within The State of California Authority Cited::Chapter 6.7,Health and Safety Code; Chapter 16,Division 3, Title 23,California Code of Regulatioms, This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be tyre areal for each monitoring gystt m 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 30 days of test date. A. General Information Facility Name:Tracy Blvd Shell&Milli Mart Bldg,No.: Site Address: 3725 N.Tracy Bivd. City: Tracy,CA 1 Zip: 95876 Facility Contact Person: Manager Contact Phone No.: (209)835.7608 Make/Model of Monitoring System: Beaudreau 522T Date of TestinglServicing: 1215811 B. Inventory of Equipment Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank f):01-Rego Tank ID. 02-Plus ❑ 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: t7 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical trine 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 1 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 IT)- 03-Prem Tank i • 04-Diesel ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: p 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: 0 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 IQ; 01-02 Dispenser Ill. 03-04 Ug Dispenser Containment Sensor(s). Model: Beaudreau 5ko C§ Dispenser Containment Sensor(s). Model: Beaudreau bio ❑ Shear Valve(s) ❑ Shear Valve(s). p Dispenser Containment Float(s)and Chain(s); ❑ Dispenser Containment Float(s)and Chain(s), Dispenser IQ. 05-06 Dispenser I - 07-08 Ig Dispenser Containment Sensor(s). Model; aeaudreau 5'10 CC Dispenser Containment Sensor(s). Model: aeaudreau sato ❑ Shear Valve(s). ❑ Shear Valve(s)• El Dispenser Containment Float(s)and Chain(s):: [l Dispenser Containment Float(s)and Chain(s). Dispenser I:D• 09-10 DispenserID' 11-12 Ig Dispenser Containment Sensor(s). Model: aeaudreau 5 0Dispenser Containment Sensor(s)_ Model: Beaudreau 510 ❑ 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 manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures`checklists)necessary to verlfy 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; (cheek aft that apply): ❑ Systein set-up ❑ Alarm history report Technician Name(print): Ryan Case_ Signature: f` M fig.Cert.#.: q tp f ICC# 8057554-UT License,No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971.2445 Testing Company Address: 680 QuinnAve., San Jose, CA 95112 Date of Testing/Servicing, 1215111