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RECEIVED OCT 01 2013 Appendix VI ENVIRONMENTAL MONITORING SYSTEM CERTIFICATION HEALTH DEPARTMENT For use By All the State of California Authority Cited:Chapter 6.7,Health and Safety Code; hapter 16dictions ,r Division 3,Title 23,California Code of Regulations This toren must be used to document testing and servicing of monitoring equipment.A separate cedification 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 farm to the local agency regulating UST systems within 30 days of test date. A. General Information Facility u=me SHELL OIL Site Bldg.No.: Address 3515 NAVY DR City; STOCKTON CA Facility Contac[ Zip: Person Contact Phone No.: ( ) Make/Model of Monitoring System: RONAN Date of Testing/Servicing: 101212012 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicatespecific equipment' ed/serviced: Tank 10: WASTE Tank ID: [IIn-TankGauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: LS D Annular Space or Vault Sensor. Model: IR Piping Sump/Trench Sensor(s). Madel: LS3 D Piping Sump/Trench Sensor(s). Model: D Fill Sump Senscr(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: D Mechanical Line Leak Detector. Model: D Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill/High-Level Sensor, Model: LS 3 ❑ Tank Overfill/High-Level Sensor. Model: D Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). TanklD: TanklD: NA D In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: D Annular Space or Vault Sensor. Model: D Annular Space or Vault Sensor. Madel: D Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: D Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Model: D Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: D Electronic Line Leak Detector. Madel: ❑ Electronic Line Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: D Other(specify equipment type and model in Section E an Page 2). D Others ( pacify equipment type and model in Section E on Page 2). DispenserlD: TRANSUMP Dispenser ID: ® Dispenser Containment Sensor(s). Model: ULS D Dispenser Containment Sensor(s). Model: D Shear Valve(s). D ShearVelve(s). ❑ Dispenser Containment Floal(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: D Dispenser Containment Sensor(s). Model: D Dispenser Containment Sensor(s). Model: D Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). [DispenserlD; DispenserlD: spenser Containment Sensor(s). Model: ❑Dispenser ContainmentSensor(s). Model: aive(s). ❑Shear Valve(s). spenser 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 Inspectetl/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): DAVE WINKLER Signature: Certification No.: 5263373-tfi License No: OB-1739 Testing Company Name. AFFORDA-TEST Phone No. _(209)7440113 Testing Company Address: 416 STREET GALT,CA 95632 Date of Testing/Servicing: 10-2-12 Monitoring System Certification Pagel of 4 2/21/07