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r • • Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Slate of Catfomia 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 ce m'uattion or provided report must the tank sbe yatemfor each monitoring system control panel by the technician who performs the work.A copy of this ownerloperator.The owner/operator must submit a copy of this torn to the local agency regulating UST systems within 30 days of test date. A. General Information Facility SHELL OIL DISTRIBUTION CENTER Bldg.No.: Alamo' Site City: STOCKTON Zip: 95203 Address' 3515 NAVY DR. Facility Contact MIKE TORRES Contact Phone No.: ( ) Person- Make/Model of Monitoring System: RONAN Date of Testing/Servicing: 101412011 B. Inventory of Equipment Tested/Certified Check thea ro rfate boxes to Indicates specific equipment ins ectad/serviced: Tank ID: WASTE WATER Tank Size: Tank ID: Tank Size: ❑ [I In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ® Annular Space or Vault Sensor. Model: LS-7 ❑ Piping Sump/Trench Sensor(s). Model: ® Piping Sump l Trench Sensor(s). Model: LS-1 Model: ❑ Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. Model: [I Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill/High-Level Sensor. Model: LS-3 [I Tank Overfill/High-Level Sensor. Model: [I❑ Other(specify equipment mart type and moOther(specify equipment type and model in Section E on Page 2). e ui del in Section E on Page 2). TankID: Tank Size: Tank ID: Tank Size: ❑ Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ An [I Piping Sump I Trench Sensor(s). Model: ❑ Piping Sump I Trench Sensor(s). Model: C1 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: [I Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: [I Electronic Line Leak Detector. Model: [I Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: [I Tank Ospeci/High-Level Sensor. Model: El Tank Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section E on Page 2). 11 Dispenser ID: TRANSITION SUMP Dispenser lD: El Dispenser Containment Sensor(s). Model: ® Dispenser Containment Sensor(s), Model: LS-1 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Flom(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dis ancien lD: Dispenser 1D: P ❑Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model ❑Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser Containment Float(s)and Chains . 'If the facility contains more tanks or dispensers,copy this form. Include irdormaticn 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 Cerfification 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): ZANE A NIMMO Signature: _ License No: 04-1676 Cedificakion No.: A26446 Phone No. 209 744-0113 Testing Company Name: AFFORDA-TEST Dale of Testing/Serviang: 10/4/11 Testing Company Address: 416 STREET GALT,CA 95632 2/21/07 Monitoring System Certification Page 1 of 4