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• Appendix V1 • HECEIVEL' (Copies of Monitoring System Certification form and USTMonitoring Plot Plan available at hup:/iwww.wtuerboardsca.gov.) MONITORING SYSTEM CERTIFICATION OCT 2 U 2015 For Use By All Jurisdictions Withal the State of California �R(�nlnA Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23,California Code ofRegulati�'dk9Ydl'26Nf ENTAL. This form must be used to document testing and servicing of monitoring equipment.A separate certification or report mus monitoring system control panel by the technician who perforans the work. A copy of this form must be provided to the tank sty rTv�t�roP491aAArm& owner/operator must submit a copy ofthis form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Shell Oil Products Facility ID: 01 Site Address: 3515 Navy Dr. City: Stockton Zip: 95203 Facility Contact Person: Miguel Torres Contact Phone No.: 916-371-6911 Make/Model of Monitoring System: Ronan X76S Date of Testing/Servicing: 2015-09-25 B. Inventory of Equipment Tested/Certifled Check the appropriate boxes to indicate specific equipment inspected/serviced: ITank ID: Slop Tank Tank ID: ❑ In-Tank Gauging Probe. Model. ,❑fn Tank Gaugurg Probe. Model: 0 Annular Space or Vault Sensor. Model: LS7 ��❑Annular Space or Vault Sensor. Model: ❑X Piping Sump/Trench Sensor(s). Model: LS3 ❑Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Settsor(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: ❑X del LS3 Tank Overfill/High-Level Sensor. Mo ❑Tank Overfill/High-Level Sensor. Model: I® Othcr(spcufv equipment it and model In Section F on Page 2) �❑Other(,peci fZ equipment IN pe and model in Sect snit F on Page 3). Tank ID: Tank ID: ❑ hi-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑ Annular Space or Vauh Sensor. Model ❑Annular Space or Vault Sensor. Model: ElPiping Sump/Trench Sensor(s). Model: El Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(,). Model: ❑Fill Sump Sensor(,). 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: ❑ (specify q 'p yp ode! in Section L'on Page'_l. ❑Other(specify equipment type and model in SectionE on Page 2). Otherequipment menu a and model Other equipment___ `-------^- Dispenser ID: Dispenser ID: w ❑ Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Seasons). Model: j❑ Shear Valve(s). ❑Shear Valve(,). j❑ Dispenser Containment Floats)and Chain(s)_ ❑Dispenser Containment Float(s)and Chain(s). i} Dispenser ID: Dispenser ID: 1❑ Dispenser Containment SO enso s . Model r '❑Drspenscr Containment Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). J1 ❑ Dispenser Containment Floats)and Chain(s). '❑Dispenser Containment Float(s)and Chain(s). "If the facility contains more tanks or dispensers,copy this form Include information forevery 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 Certifications information(e.g.manufacturers' checklists)necessary to verify that this information is comectand a Plot Plan showing the layout of monitoring equipment For any equipment capable of generating such reports,I have alsoattached a copy of the report;(check all thatapply) : ❑ System set-up ❑Alarm history report Technician Name(print): Victor Guerrero I/arm Op?AR W Signature: ll// Certification No.: 76130702 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 sorrmoueorrrue Ve AwuroMr.AWW6 Date ofTestin Sery icing:g: 2015-09-25