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Monitoring System m Certification For Use By Alf Jurisdictions Within The State of California Authority Cited.-Chapter 67,Health and Sateiy Code;Chapter 16,Division 3, Title 23, California Code of Regulatioris This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each mgnitoring system control Impel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator roust 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&Mini Mart }Y Bldg No.: Site Address: 3725 N.Tracy Blvd. City: Trac CA Zip: 95376 Facility Contact Person: Manager Contact Phone No.: (209}835-7608 Make/Model of Monitoring System: Beaudreau 522T Date of Testing/Servicing: 12/5111 B. inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: 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). Models ❑ 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). 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. Models p Piping Sump t Trench Sensor(a). Model: ❑ Piping Sump\Trench Sensor(s): Moder: ❑ Till Sump Sensor(s). Model:. ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Eiectronic 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• 13-14 Dispenser Ill• 15-16 M Dispenser Containment Sensor(s). Modcl: Beaudreau 510 Ul Dispenser Containment Sensor(s). Model: aeaudreau 510 ❑ Shear Valve(s), 0 Shear Valve(s), ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s); Dispenser IT? Dispenser ID• ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Q Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s): ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID Dispenser ID• ❑ Dispenser Containment Sensor(s)., Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). [7 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• r 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 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; (check all thatapply): ❑ System set-up ❑ Alarm history report "technician Name(print):Ryan Casey Signature Mfg.Cert.#.: lCC# 8057554-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: 12/5/11