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• Appendix V1 • : , ass - a' ` E® (Copies of Monitoring System Cettificationfonn and USTMonitoring Plot Plan available at http://www.waL-tboardITORING SYSTEM CERTIFICATION Vol��I 2��4 For Use By All Jurisdictions Withdt the State ofCalifarnia Authorhy Cited.Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23,California Code ofRegulatians j. ��.TF This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared far each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system dwnerCeach Cot'.'"ffie owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days 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.: 916-439-3477 Make/Model of Monitoring System: Ronan Date of Testing/S ervicing: 9/29/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: F' [n-Tank ID: Slop Tank _. , Tank ID: F Gauging Probe. Model r In-Tank Gauging Probe. Model: nular Space or Vault Sensor. Model:LS7 r Annular Space or Vault Sensor. Model: ping Sump/Trench Sensor(s). Model: LS3 r PipingSump/Trench Sensor(s). Model: l Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: echanical 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 LS3 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). Tank ID: Tank ID: r ti-Tank Gauging Probe. Model: r In-Tank Gauging Probe. Model: r 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: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model r Electronic Line Leak Detector. Model: r Tank Overfill/High-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 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 Float(s)and Chain(s). Dispenser ID: DiSpenser W. r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: F Shear Valve(s). r Shear Vatve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). *if the facility contains rrore tanks ordispensers,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 Certification is information(e.g.manufacturers' checklists)necessary to verify that this information is coumtand 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 Nurtapply) : r System set-up r Alarm history report Technician Name(print): Vicbr Guerrero /� r'� Signature: �/ �i{rtnw.�i Certification No.: 76130702 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2i31801M1DUP0WDaWEAXAHEJMCA9W6 Date ofTesting/Sery icing: 9/29/2014