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MonitorindbSystem Equipment,bertification 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 pancl by the technician who perforans 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 system within 30 days of test date. A. General Information Facility Name:Northside Shell Bldg.No.: Site Address: 7910 Sacramento Rd. @ Hammer Lane City: Stockton, CA Zip: 95210 Facility Contact Person: Billy Contact Phone No.: (209)472-7748 Make/Model of Monitoring System: VIR Simplicity Date of Testing/Servicing: 6123104 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/servieed: Tank ID:01-Regu Tank ID: 02-Plus ❑ In-Tank Gauging Probe. Model: VR 847390-107 ❑ In-Tank Gauging Probe. Model: VR 847390-107 Annular Space or Vault Sensor. Model: VR 794380-302 Annular Space or Vault Sensor. Model: VR 794330-302 Piping Sump 1 Trench Sensor(s). Model: VR 79438M62 Piping Sump 1 Trench Sensor(s). Model: VR 794380.352 Cl Fill Sump Sensor(s). Model: None ❑ Fill Sump Sensor(s). Model: None ❑ Mcchamcal Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None Electronic Line Leak Detector. Model: VR Series 8484 Electronic Line Leak Detector. Model: VR series 8484 ❑ Tank Overfill\High-Level Sensor. Model: None ❑ Tank Overfill\High-Level Sensor. Model: None 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: 03-Prem Tank ID: 04-Waste Oil ❑ In-Tank Gauging Probe. Model: VR 847390-107 0 In-Tank Gauging Probe. Model: None 8 Annular Space or Vault Sensor. Model: VR 794380302 6 Annular Space or Vault Sensor. Model: VR 794390420 19 Piping Sump 1 Trench Sensor(s). Model: VR 794380-352 ❑ Piping Sump 1 Trench Sensor(s). Model: None E] Fill Sump Sensor(s). Model: None ❑ Fill Sump Sensor(s). Model: None ❑ Mechanical Line Leak Detector. Model: None ❑ Meehanical Line Leak Detector. Model: None Electronic Line Leak Detector. Model: VR series 8484 Q Electronic Line Leak Detector. Model: None ❑ Tank Overfill\High-Level Sensor. Model: None Tank Overfill\High-Level Sensor. Model: VR 794390.420 ❑ 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: 01-02 Dispenser ID: 03-04 1N Dispenser Containment Sensor(s). Model: Beaudrou 406 Dispenser Containment Sensor(s). Model: Beaudrou 406 6 Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). 05-06 Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Beaudrou 406 ❑ Dispenser Containment Sensor(s). Model: 7 Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Fioat(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ? ❑ Dispenser Containment Sensor(s). Model: y ❑ Shear Vaive(s). I7 Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Cl 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 impected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'cheeldists)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; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name(print):SSS-Ronal Signature: Certification No.: 006-05-0826 License.No.: 485184 Testing Company Name:Ser. Sta. Sys. Phone No.: (408)971-2445 Site Address: 7910 Sacramento Rd. @'Hammer Lane Date of Testing/Servicing: 6123104