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MonitorhoSystem Equipment4Werfiflcation For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each 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 within 30 days of test date. A. General Information Facility Name: Shell 136187 Bldg. No.: Site Address: 2375 W. Grant Line @ 1-205 City: Tracy, CA Zip: 95376 Facility Contact Person: Shauna Contact Phone No.: (209) 836-8908 Make/Model of Monitoring System: V/R Simplicity Date of Testing/Servicing: 05/08/02 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: TankID: TankID: ❑ In - Tank Gauging Probe. Model: ? ❑ In - Tank Gauging Probe. Model: ? ❑ Annular Space or Vault Sensor. Model: ? ❑ Annular Space or Vault Sensor. Model: ? ❑ Piping Sump \ Trench Sensor (s). Model: ? ❑ Piping Sump \ Trench Sensor (s). Model: ? ❑ Fill Sump Sensor (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: ? ❑ Tank Overfill \ High -Level Sensor. Model: ? ❑ Tank Overfill \ High -Level Sensor. Model: ? ❑ Other ( specify equipment type and model in Section E on Page 2). [1Other ( specify equipment type and model in Section E on Page 2). TankID: TankID: ❑ In - Tank Gauging Probe. Model: ? ❑ hi - Tank Gauging Probe. Model: ? ❑ Annular Space or Vault Sensor. Model: ? ❑ Annular Space or Vault Sensor. Model: ? ❑ Piping Sump \ Trench Sensor (s). Model: ? ❑ Piping Sump \ Trench Sensor (s). Model: ? ❑ Fill Sump Sensor (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: ? ❑ Tank Overfill \ High -Level Sensor. Model: ? ❑ Tank Overfill \ High -Level Sensor. Model: ? ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ Other ( specify equipment type and model in Section E on Page 2). Dispenser ID.. 13-14 Dispenser ID- 15-16 ❑ Dispenser Containment Sensor (s). Model: None ❑ Dispenser Containment Sensor (s). Model: None Ig Shear Valve (s). 99 Shear Valve (s). 11 Dispenser Containment Float (s) and Chain (s). J1 Dispenser Containment Float (s) and Chain (s). Dispenser ID- 17-16 Dispenser ID: 19-20 ❑ Dispenser Containment Sensor (s). Model: None ❑ Dispenser Containment Sensor (s). Model: None (19 Shear Valve (s). QQ Shear Valve (s). Ig Dispenser Containment Float (s) and Chain (s). 99 Dispenser Containment Float (s) and Chain (s). Dispenser ID• 21-22 Dispenser ID• ❑ Dispenser Containment Sensor (s). Model: None ❑ Dispenser Containment Sensor (s). Model: 99 Shear Valve (s). ❑ Shear Valve (s). Qg Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). *If the 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 manufacturer's guidelines. Attached to this Certification is information (e.g. manufactures' checklists ) necessary to verify that this information is correct and a Plot Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the; ( check all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): SSS -Josh Signature: Original on file at SSS Certification No.: 552-61-6176 License. No.: 485184 Testing Company Name: Ser. Sta. Sys. Phone No.: (408) 971-2445 Site Address: 2375 W. Grant Line @ 1-205 Date of Testing/Servicing: 05/08/02