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JUL-04-2011 09:52 Service Station Systems 408 938 8888 P.08 Monitoring system 11Equipment Certification l or U,se By All Jurisdictions Within The State of California Authority Cited. Chapter 6,7, Health and Safety Code; Chapter 16, Division.?, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A seg certification or report must be pr aced for cagh monitoring aystem_st2ntrpl panel by the technician who performs the Work, A copy of this form must be provided to the lank system owner/operator, The owner/operator must submit a copy of this form to the local agency regulating UST system within 30 days of test date. A. General Information Facility Name:Shell 136187 Bldg, No.: Site Address: 2375 W Grant Line City: Tracy,CA _ Zip: 95376 Facility Contact Person-. Manager Contact Phone No.: (209 ,836M8908 Make/Model of Monitoring System: Beaudreau 522T Date of Testing/Servicing: 6110/11 R. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank[ Tank I1L 13 In-Tank Gauging Probe. Model: Cl In-Tank Gauging Probe. Model: Cl Annular Space or Vault Sensor, Model: C1 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; E3 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: C3 Electronic Lina Leak Detector, Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-level Sensor. Model: E3 Other(specify equipment type and model in Section E on Page Z). ❑ Other(specify equipment type and model in Section F.,on Page 2), Tank Ir• Tank Imo• - — Cl In-Tank Gauging Probe. Model: ❑ in-Tank Gauging Probe. Model; ❑ Annular space or Vault Sensor, Model: G Annular Spaca or Vault Sensor. Model: 0 Piping Sump\Trench Sensor(s). Model; ❑ Piping Sump\Trench Sensor(e). Model: t3 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: ❑ Mechanical Line Lrik Detector, Model: Ca Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Mculd; ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\high-Level Sensor. Model; C] other(specify equipment type and model in Section k on Page 2), ❑ Other(specify equipment type and model in Section E on Page 2). ID• 13-14 01spenser ID,a Thspenser Containment Scnsnr(s). Model; ftaodmaaE03100 e a DispenserContainment Sensor(s). Model; 598140*eau EOS1E:6[,Dispenser Shear Valve(s), a Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). C3 Dispenser Containment Flout(s)and Chain(s). Mspenser ID; 17.18 Dispenser in19.20 ® pispcnscr Containment Sensor(s). Model: gMu ePsPs'O" a Dispenser Containment Sensor(s). Modcl: Eiaaudrehw E097o0 s a Shear Valve W. a Shcar Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s), Dispenser ID• 21-22 Dispenser ID• N Dispenser Containment Sensor(s). Model: tmudranu E051004 ❑ Dispenser Containment Sctmr(s). Model: is Shear Valvc(s). ❑ Shear Valve W. ❑ 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 infortnatinn 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 manuf'acturer's guidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verify that this information is correct and 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; (chock,an diatapply). 0 System set-up ❑ Alarm history report Technician Name(print):Bryan Lundeen Signature: -- Mfg.Cert.#,: ICC# 8001468-UT Liccnse.No.: 485184 Testing Company Name: Service Station Systems Phone No,: 408 971-2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 95112 mate of Testing/Servicing: 6110111