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' • Appendix VI • RECEIVED (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.w mo s.M. ov.) MONITORING SYSTEM CERTIFICATION V� 3 6 2014 For Use By All Jurisdictions Within the State ofCa/ifornia Authority Cited.Chapter 67,Health and Safety Coder Chapser l6,Division 3, Tule 23,California Code ofRegulatEWIRONMENTAL HEALTH This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be KIRWWfMMCES 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 systems widrin 30 d ays of test date. A. General Information Facility Name: Shell Oil Products Building No.: 01 Site Address: 3515 Navy Dr. City: Stockton Zip: 95203 Facility Contact Person: Miguel Torres Contact Phone No.: 916439-3477 Make/Model of Monitoring System: Ronan Date of Testing/Servicing: 10/24/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: Slop Tank Tank ID: r lin-Tank Gauging Probe. Model: r In-Tank Gauging Probe. Model: * Annular Space or Vault Sensor. Model:LS7 r Annular Space or Vault Sensor. Model: r Piping Sump/Trench Sensor(s). Model: LS3 r Piping Sump/Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanierd Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: F Tank Overfill/High-Level Sensor. Model: LS3 r Tank Overfill/High-Level Sensor. Model: W Other(specify equipment type arid model in Section E on Page 2). 7 Other(specify equipment tope and model in Section E on Pace y). Tank ID: ',. Tank ID: r In-Tank Gauging Probe. Model: r In-Tank Ganging Probe. Model: r Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: r Piping Sump/Trench Sensor(s). Model: r Piping Sump/Trench Seasor(s), Model: F Fill Sump Semor(s). Model: r Fill Sump Sensor(s). Model: F Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: F Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: F Tank Overfill/Fligh-Level Sensor. Model: r Tank Overfill/High-Level Sensor. Model: r Other(specify equipment type and model in Section E on Page 2). r Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: r Dispenser Containment Senmgs). Model: r Dispenser Containment Senrot(s). Model: F Shear Valve(s). r Shear Valve(s). IF Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). ...._ _... .._.. Dispenser ID: Dispenser ID: r Dispenser Containment Senw r(s). Model: r Dispenser Containment S en se t(s). Model: r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chan(s). "If the facility curtains mere tanks ordispensers,copy this forth.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 informations correct and a Plot Plan showing the layout of monitoring equgrmenL For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply) : r System set-up r Alarm history report Technician Name(print): Victor Guerrero Yt� /_..._...�� Signature: ��`�"'�� Certification No.: 76130702 License.No.: 588098 Tearing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131s0UTH1ue0wruwE,n MACASzwe Date of Testing/Servicing: 10/24/2014