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• Appendix V1 • RECEIVED (Copies of Monitoring System Certification fornt and UST Monitoring Plot Plan available at http://www.watetboards.ca.gov.) MONITORING SYSTEM CERTIFICATION OCT 2 0 2014 For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 67,Health and Safety Cade;Chapter 16,Division 3, Tule 23,California Code of Re ulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or re ttWkQP0&6T)ALhHEALTH monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the taakDEpX �rvv�t ppeRT. The owner/operator must submit atopy of this form to the local agency regulating UST systems within 30 days of test date. CC��VV II A. General Information Facility Name: Shell Oil Products BuildingNo.: 01 Site Address: 3515 Navy Dr. City: Stockton Zip: 95203 Facility Contact Person: Miguel Torres Contact Phone No.: 916-439-3477 Make/Model of Momtoring System Ronan Date of Testing/Servicing: 9/29/2014 B. Inventory of Equipment Tested/Certifed Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: Slop Tank Tank ID: � r ]n-Tank Gauging Probe. Model: r In-Tank Gauging Probe. Model: F Annular Space or Vault Sensor. Model: LS7 r Annular Space or Vault Sensor. Model: F Piping Sump/Trench Sensor(s). Model LS3 Piping Sump/Trench Sensor(s). Model- r- Fill Sump Sensor(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/High-Level Sensor. Model LS3 r Tank Overfill/High-Level Sensor. Model: F Other(specify equipment type and model in Section E on Page 2). r Other(specify equipment type and model in Section F on Pace 2). Tank ID: Tank ID: r In-Tank Gauging Probe. Model: r In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: F Piping Sump/Trench Sensor(s). Model: r Piping Sump/Trench Sensor(s). Model: F Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: F Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: F Tank Overfill/High-Level Sensor. Model: r Tank Overfill/high-Level Sensor. Model: F Other(specify equipment type and model in Section on Page 2). r Other(specify equipment type and model in Section F on Page 2). Dispenser IDDispenser ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Floats)and Chants). Dispenser ID: Dispenser ID: F Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensors). Model: r Shear Valve(s). r Shea-Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). *If the facdmty comrai ns 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 inspected/serviced in accordance with the manufacturers' guidelines.Attached to this Certifications information(e.g.manufacturers' checklists)necessary to verify that this information is correctand 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) : r System set-up r Alarm history report Technician Name(print): Vicbr Guerrero �J� Signature: Y Certification No.: 76130702 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131sotrrnotmoxrmrvE,nnwtmM,CA92806 Date of Testing/Sery icing: 9/29/2014