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JUL-04-2011 09:50 Service Station Systems 408 938 8888 P.03 Monitoring stem Equipment Certiflication For Use By All Jurisdictions Within The State of California Authority Cited.' Chapter 6.7, Health and Safety Code.Chapter 16, Divb don 3, Title 23, Cul fornia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A e aratc ecrt ion or renort trust prerlared for each monit rin>a systerrt control l by the technician who performs the work. A copy of this form must be provided to the tank eyetem o tmer/oporsitor. The otxmerJnjvaratnr mimi c,il+mit a angry of this fArm to the local asency reeuiating UST systcm 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.: 209 836-8908 Make/Model of.Monitoring System: V1R Simpllci _ Date of Testing/Servicing: 6/10111 B. Inventory of Equipment Tested/Certlfied Cheek the appropriate boxes to indicate specific equipment inspected/serviced: Tank 10.01-2292 Tank, • 02-Plus ❑ in-'rank Gauging Probe. Model; VR 6473911.107 ❑ In-Tank Gauging Probe. Model: VR 647390.107 N Annular Space or Vault Sensor, Model: VR 7943W301 ® Annular Space or Vault Sensor. Model: VR 7@4390.301 0 Piping Sump\Trench Sensor(s). Modcl vR 7o4NO-208 _ a Piping Sump\Tronch Sensor(s). Model: VR 794sso-208 0 Fill Sump Sensor(s). Model: yR 794360308 Fill Sump Sensor(s). Model: VR 794380-200 ❑ Mechanical Line Leak Detector. Model: Cl Mechanical Tine Leak Detector. Model: Electronic Line Leak Detector. Model: VR Sort-"" ® Electronic Line Leak Detector. Model: VR Servs 8484 p 'Tank Overfill\High-Level Sensor. Model' ❑ Tank Overfill\High-Level Sensor. Model: Cl Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section F,on Page 2). Tank In• 03-Prom Tank Ilt 04•Die5el C1 In•Tank Gauging Probe. Model: VR 847390107 [3 In-Tank Gauging Probe. Model; VR 847390.107 ® Annular Space or Vault Sensor. Model: VR 794360-301 Annular Space or Vault Sensor. Model: VR 79438001 Ig Piping Sump\Trench Sensor(s). Model;- VR 794380 Y52. _._ Piping Sump\"Trench Sensor(s). Model; vR 794340.208 a Fill Sump Sensor(s). Model; yR 7s<38o30a Cii rill Sump Sensor(s). Model: VR 79t300-xo8 ❑ Mechanical Line Leak Detector. Model; ❑ Mechanical Line Leak Detector. Model: 0 Electronic Tine Leak Detector. Model: VR seriea 4484 ® Electronic Line Leak Detector. Model; VR Sanas ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-L4;vcl Sensor. Model: — ❑ Other(specify equipment type and model in Section E on Page 2), Q Other(specify equipment type and model in Section E on Page 2), Dispenser I • Dispenser I% ❑ Dispenser Containment Sensor(s). Model; ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID• Dispenser Its,°„ - 13 Dispenser Containment Sensor(s). Model; ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve W. ❑ Shear valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s), Dispenser Dl$ eraser ID' ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear valve 0). ❑ Shear`halve(s). Q Dispense'Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(a)and(Thain(s). •Ifthe facility contains more tanks or dispensers,copy this forth,include information for every tank and dispenser at the facility C.Certification- l certify that the equipment identified in this document was inspcetcdtservieed 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 Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,t have also attached a copy of the-, (cheek all(hot oRdy), ❑ System set-up ❑ Alarm history report Technician Name(print):Bryan Lundien Signature: Mfg,Cert.#.: B36094 ICC# 8001_468-UT License.No.: 485184 Testing Company Nam`: Service Station Systems Phone No.: (408)971.2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 95112 Tate of Testing/Servicing: 6/10111