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.Monitoring System Certification* W L��L�� V For Use By All Jurisdictions Within the State of California �f)j ` `/FrR D 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 mu�[(IQ8T5r6pad�pn'�ich Eon, system control panel by the technician who performs the work.A copy ofT is orm mus a provioeu��,a, >�� •• •�••-.-L--or.The ow er opera or mus su mi a copy of this form to the local agency regulating UST systems within 30 days of test daENVIRONMENT HEALTH A. General Information I o: Facilit : Shell Address: 3515 NavyDr. City: Stockton Zip: 95203 Facility Contact Person: Carlton Jordan I Contact Phone No: 310-629-8826 Make/Model of Monitoring System: Ronan X765-A4 jService Date: 10/14/2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment Inspected/serviced: Tank ID: UST Slop Tank Tank ID: ❑In-Tank Gauging Probe Model: ❑In-Tank Gauging Probe Model: ®Annular Space or Vault Sensor Model:LS-7 ❑Annular Space or Vault Sensor Model: ®Piping Sump/Trench Sensor(s) Modei:LS-3 ❑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:LS-3 ❑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) TanklD: TanklD: ❑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: ❑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: 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) 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) DispenserlD• 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) "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 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): Graham Stephen Signature: Certification No: 796980805 License No: 588098 Testing Company Name: TAIT ENVIRONMENTAL Phone No: (714)560-8222 SERVICES Pagel of 4