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JAN-20-2012 11:10 Ser t:e Station Systems 408 938 8888 P.08 Monitoring System e Certification For Use By Alf Jurisdictions Within The State of California Authority Cited.Chapter 6.7, -leahh and Safety Code;Chapter 16, Division i, Title.23, California C:oile of 12egulaliont This form must be used to document testing and servicing ot'monitoring c cluigment. A&c .ttrale jrjiQn„ r repntmot be pparcd for each monitoring system contrgLWDcl 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 forth to the local agency regulating UST system within 30 days of test date. A. General Information Facility Name:Tracy Blvd Shell&.Mini Mart Bldg. No.: Site Address: 3725 N.Tragi Blvd. City: Tracy, CA Zig: 95376 Facility Contact Person: Manager Contact Phone No.: (209)855.7608 Make/Model of Monitoring System; Beaudreau 522T Date of Testing/Servicing; 115/12 B. Inventory of.Equipment Tested/Certified Check the appropriate boxes to indicate speCific equipment inspected/serviced: Tank 111 Tatnk ID• ❑ in-Tank Gauging Probe. Modcl: [7 in-Tank Gauging Probe Model: _ Cl Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model, ❑ Piping Sump\Trench Sensor(s). Model: p Piping Sump\'I*mnc:h Sensor(s), Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: M Mechanical Line Leak Detector, Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overni I\High-Level Sonsor. Model: ❑ 'rank Overfill\Higlt-Level Sensor. Model; ❑ Other(specify equipment type and model in Section C on Fags 2). ❑ Other(specify equipment type and model in Section E on Puge 2). Tank in, 'rank ID: ❑ In-Tank Gauging Prone. Model: ❑ In-Tank Gauging Probe, Model: ❑ Annular Spacc or Vault Sensor. Model; 13 Annular Space or Vault Sensor, Model: ❑ Piping Sump\Trench Sensor(s). Model; 0 Piping Sump\Trench Sensor(s). Model: ❑ Fit Sump Sensor(s). Model; Cl Fill Sump Sensor(s). Model; 0 Mechanical Line Leak Detector Model: ❑ Mechanical Lino Lcak Detector. Model; ❑ Electronic Line Leak Detector. Model: ❑ Flectmnie Linc Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor, Model: C] 'rank Overfill\Iligh-level Sensor. Model: ]1 Other(specify equipment type and model in Section E on Page 2), ❑ Other,(apccity equipment type and model in Section 6 on Page 2). Dispenser ID• 13.14 Dispenser 111: 15-16 3 Dispenser Containment Sen$Or(S). Model: Beau_d.resu 510 N Disrcnecr Containment Sensor(s), Model: aeaudreau Sic Shear Valve(s). 11 Shear Valve(s). Q Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser IQ* C1 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s), Model; C Shear Valve(s), ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s), C] Dispenser Containment Float(s)and Chain(s). Dispenser iD: INspenser ID; r] Dispenser Containment Sensor(s). Model; ❑ Dispenser Containment Sensor(s)• Modch ❑ Shear Valve(s). ❑ Shear Valve(s). E3 Dispenser Containment Moat(s)and Chain W. Cl Dispenser Containment Float(s)and Chain(s). "If cite facility contains 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 Certification is information(e,g.manufactures`checklists)necessary to verify that this information is correct and it Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the; (cheek All that apply), t] Systern set-up ❑ Alarm history report Technician Name(print):Randy Wilkerson Signature: i JUL Mfg.Cert.#,: ICC# 5258560-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 95112 pate of Testing/Scrvicing: 1/6112