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NIT RING SYSTEM CERTIFICATION Use By Alt Jurisdictions within the State of Cie ifo Authority Cited: Chapter 6.7, Ith and Safety Code; Chapter 16, Division 3 Ttle 2 , ifomia Code of Regulations This form must be used to document testing and servicing of monitoring equipment If more than one monitoring system control panel is installed at the facility, a separate certification or report must be prepared for each monitoring 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 systems within 30 days of test date. A. General Information Facility Name: SHELL # 136186 Site Address: 3725 N. TRACY BLVD Facility Contact Person: MANAGER Make/Model of Monitoring System: BEI 522 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced City: TRACY CA Zip: 95376 Contact Phone No: 835-7608 Date of Testing/Service: 12/22/2009 Work Order Number: 2271161 TanklD: 87 TanklD: 89 In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: El 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). X Other (specify equipment type and model in Section E on page 2). TanklD: 91 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: 39 Other (specify equipment type and model in Section E on page 2). X Other (specify equipment type and model in Section E on page 2). Dispenser : 1/2 Dispenser ID: 3/4 ® Dispenser Containment Sensor(s) Model: 406/508 _X__j Dispenser Containment Sensor(s) Model: 406/508 XJ Shear Valve(s). X Shear Valve(s) Dispenser Containment Float(s) and Chain(s). 7 Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 0 Dispenser Containment Sensor(s) Model: 406/508 X Dispenser Containment Sensor(s). Model: 406/508 X❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). 7 Dispenser Containment Float(s) and Chain(s). DispenserlD: 9/10 DispenserlD: 11/12 X❑ Dispenser Containment Sensor(s) Model: 406/508 X Dispenser Containment Sensor(s). Model: 406/508 a Shear Valve(s). X Shear Valve(s). 10 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 Site 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 that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): CHARLES FERRUCCI / f Signature: /6 Certification No.: License. No.: 743160 (Class 'A' General Enginering Contractor License) Testing Company Name: Tanknology Phone No.: (800) 800-4633 Site Address: 11000 N. MoPac Expressway, suite 500, Austin, TX 78759 Date of Testing/Servicing: 12/22/2009 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/08