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y ONIT RING SYSTEM CETIFI TION Use By Al'j Jurisdictions Vthin the State of Califon Authority Cited.Chapter 6.7,111th and Safety Code;Chapter 16, Division 3 Title 23, lifornia 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 CC#136187 City: TRACY CA Zip:95376 Site Address: 2375 WEST GRANT LINE ROAD Contact Phone No: 836-8908 N-1094-1-5 Date of Testing/Service: 05/28/2010 Facility Contact Person: MANAGER Make/Model of Monitoring System:VR-SIMPLICITY Work Order Number: 2274700 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: T1-REG Tank ID: T2-PLUS X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 301 21 Annular Space or Vault Sensor. Model: 301 71 Piping Sump/Trench Sensor(s). Model: 352/2087X352/208 Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensogs). Model: 208 208 Fill Sump Sensor(s), Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: PLLD X Electronic Line Leak Detector. Model: PLLD X Tank Overfill/High-Level Sensor. Model: BALL FLTS Tank Overfill/High-Level Sensor. Model: BALL FLTS 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: MAG In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 301 71 Annular Space or Vault Sensor. Model: 301 X Piping Sump/Trench Sensor(s). Model: 352/352 X Piping Sumprrrench Sensogs). Model: 352 X Fill Sump Sensogs). Model: 208 X Fill Sump Sensogs). Model: 208 Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: PLLD X Electronic Line Leak Detector. Model: WPLLD Tank Overfill/High-Level Sensor. Model: BALL FLTS Tank Overfill/High-Level Sensor. Model: BALL FLTS 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 Dispenser ID: 7 Dispenser Containment Sensors) Model: Dispenser Containment Sensors) Model: Shear Valve(s). Shear Valve(s) E]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 Sensors). Model: F] Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ® Dispenser Containment Sensors) Model: Dispenser Containment Sensors). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ED 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 1 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): ❑X System set-up ®Alarm history report Technician Name(print): KELVIN CRUZ Signature: (� Certification No.: A22519 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: 05/28/2010 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/08