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0 RECEIVED MONITORING SYSTEM CERTIFICATION APR 0 9 2018 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 ENVIRONMENTAL This form must be used to document testing and servicing of monitoring equipment. A separate certification or report monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the to sys em owner/operator. NT 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 1-5 Bldg.No.: Site Address: 717 W. Eighth St. City: Stockton Zip: 95206 Facility Contact Person: Owner-Joe Contact Phone No.: (209) 939-0961 Make/Model of Monitoring System: Veederoot TLS350 Date of Testing/Servicing: 3/8/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: #1-Regular Tank ID: #2-Premium ®In-Tank Gauging Probe. Model: 847390-109 ®In-Tank Gauging Probe. Model: 847390-109 ®Annular Space or Vault Sensor. Model: 794390-303 ®Annular Space or Vault Sensor. Model: 794390-303 w Split tank ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Fill Sump Sensor(s). Model: 794380-208 ®Fill Sump Sensor(s). Model: 794380-208 ®Mechanical Line Leak Detector. Model: Veederoot FX1 V ®Mechanical Line Leak Detector. Model: VMI LD2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: ATG ®Tank Overfill/High-Level Sensor. Model: ATG ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: #3-Diesel Tank ID: ®In-Tank Gauging Probe. Model: 847390-109 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: Split tank w/Prem ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensor(s). Model: 794380-208 ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: VMI LD2000 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: ATG ❑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: 1-2 Dispenser ID: 3-4 N Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 N Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Shear Valve(s). ®Shear Valve(s). ❑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 manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' 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 report;(check all that apply): ❑System set-up ®Alarm history report Technician Name(print): Jeff Conger Signature: Certification No.: A22219 License.No.: ICC#1801782 UT CSLB#894932 Testing Company Name: Pinnacle Fuel Compliance Services, Inc. Phone No.:(408) 206-9840 Testing Company Address: P.O. Box 32849 San Jose, CA 95152-2849 Date of Testing/Servicing: 3/8/2018 Page 1 of 3