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R MONITOUNG SYSTEM CETIFI TION 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, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. 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 syst f ED A. General Information Facility Name SHELL 1-5 Site Address: 717 W. 8th, Street MAY 0 6 2011 Bldg. No.: City: Stockton Zip: 95206 Facility Contact Person: Joe Dangtran Co -0961 Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 4/19/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: T-1 Tank ID: T-2 Z In -Tank Gauging Probe. Model: 109 Z In -Tank Gauging Probe. Model: 109 Z Annular Space or Vault Sensor. Model: 303 ® Annular Space or Vault Sensor. Model: 303 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model 208 ® Mechanical Line Leak Detector. Model: FX1V Z Mechanical Line Leak Detector. Model: 99LD2000 ❑ 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: T-3 Tank ID: ❑ In -Tank Gauging Probe. Model: Z In -Tank Gauging Probe. Model: 109 ® Annular Space or Vault Sensor. Model: 303 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ® Fill'Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FX1 DV ❑ 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). Dispenser ID: 1/2 Dispenser ID: 314 Z Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 718 Z Dispenser Containment Sensor(s). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11112 Z Dispenser Containment Sensor(s). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z 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 manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' 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 report; (check all that apply): ® System set-up ® Alarm history report Technician Name (print): Guadalupe Sanchez Signature: Certification No.: A30138 License. No.: 883706 Testing Company Name: Reliable Petroleum Services Inc. Phone No.: (209) 845-8586 Testing Company Address: 11930 Horseshoe Road, Oakdale CA 95361 Date of Testing/Servicing: 4/19/2011 Page 1 of 3 Rev (2/08)