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1+2/1912009 19:55 4089715 SSS INC 41 PAGE 02 <br /> Monitoring System Equipment Certification <br /> For Use By A11 durisdictloris With in The State Of.C[aliforrriti <br /> Authority C.iied: Cliopler 67, Hea)th rtizcl S(,fr C.'ocic, Chapter 16 Division 3, Title 23, Califon7ita Code of Re;�>>ulnta.ons <br /> '%'bis fon,•t 1-nLtSL be used to document testing and servicing of monitoring equipment. A separate_ cettifiicadorn or rebotrtmttstbe <br /> prepared for each monitoring systetn control panel by fhe tecluiician who performs the work.A copy of this fonn must be provided <br /> to the tank system owner/Cfg.Usei-Name. The owlicr/Cfg•UscrName must submit 1 copy of this form to the local agency reguiattng UST sy: <br /> within 30 clays of test date. <br /> A. General Information <br /> facility Nan,n: Northside.Shell Bldg.No.: <br /> Site r'lddress: 7910 Sacramento Rd.@ Hammer Lane City: Stockton, CA Zip: 95210 <br /> Facility Contact Pei-son: Sandhu CVtttuc:t Phone No.. �209) 472-7748 <br /> MakelModel of Monitoring Systcnt:_V/R Simplicity Date of Testing/Servicing: 11113103 <br /> I;. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicate specific equipment iuspcctcdlSorvice(It <br /> 01 -Rego Taint YD, 02-Plus <br /> rank ID: VR 647 39 0-1 0 7 ❑ In-TankGauging.Probe- Model= VR 847390-107 <br /> Q to-'funk Gauging Probe. Modell <br /> 00 Annular Space ur VuUII Scltsnr. Modci: VR 794380.302 Annular'SpaCC(,r Vault SensOt', MOttcl: VR 944360.902 <br /> (g Pipingtiunlp 1'French S@rtSOT(S). <br /> Model; VR79�4�360-352 Qy Piping Sump t lrenctl Sensor(sNone <br /> ). Modci;„ as-aaz <br /> 13 Fi11 SUMP Sen,ur(b), Modcl' None ❑ Dill Sump Sensol,(s)• Model: None <br /> Q , , None ❑ Mechanical Line Leak DciCetnr. Modtl; Nano <br /> Mtchasticall-,ineLcalcF�atret0t'. Mu(lel; Vrzc�rraaRaaa <br /> E=lectronic Line t.cak DeLctur, Mattel; VR$arias 5484 Q9 Llecu'anlc I..inc l cant�t tc slur, Mulct; <br /> Tank Overfill%Flt h-Level Sensor. Moctcl: None <br /> ❑ Tank C)vcrlill 1 illgl,-I.cvt:l Seltsar, Mtadcl: Mone ❑ 8 <br /> ❑ (kher(specify equips-neat type Incl TnOdCl ill SCCtion F'.nn Page 2), ❑ otlisr(spocil'y equipment type and model in SCCtion 2 on Page 2), <br /> Tank II3' 03-Prem Tank[ U4'Warts Oil <br /> ❑ In-Tank Ciauoing Probe, Model: VR 847359•107 p In lank Gauging Nraln• Modci: None <br /> 99 L <br /> :il ace or Vault.`ienvu,^. Mattel_ va reazan.ana finPtiilZl'ctSaCC or Vuull Sensor, U]tsdCL' VR 794196.4245 <br /> Sunip tTrcnch Sensor(s). Modul, VR 794380-962 ❑ Piping SUMP%'french SeIlSOI'(3)- Misti0l:_N4^c <br /> Fill Sum Sensor s. Model: None <br /> Fill ,p 3eltsor(s), Ntoticl: None Q p { ) <br /> riiaal Littu Leak.fletccwr. rvtnirl None t i Mt el,anicaV Line Leak l�etec4t>r. Model: None <br /> ❑ F.lectrtmic Line Leak pt;tuctnr. Model: Nano <br /> vcLine Leal(l etcl se Model: VR Non erlee e4tta 9 Tank Overlill 1 High-Level Scnsor. Model;- VR 794396.420 <br /> vcrtilll!•ti�,h-Lt:Vel5cn8nr. Muriel; None <br /> specii},ccildpmt:nt tVne and model in Suction F on ruse 2), ❑ Other(specify cquipmt:nt type and n,ndcl in Scetion E on Pagc 2). <br /> Dispenser 1D' p1"02 Dispenser 1D' 03 0A <br /> DISp ®ceutlrau 406 <br /> Diel>cnticr('unCainillent SCnanl'(s). Modci= seaudrou 465 09 F)ispcnser C'ontainrncrtt Sensor(s}. Model; <br /> g9 Shuur ValvC(s)- p9 slivit valve{s). <br /> [� oispcnsur Containment Float(s)anti Chain W. ❑ Dispo'scr Ctsnwinntent Float(s)and Chain(s). <br /> Dispenser I - 05-06 Dispenser TD- <br /> (� I]i9penscr Coniainn,ent Sunt os'(s). Motel: Zea udrau 4-06 _— ❑ Dispenser C(intainment Sensor(s)• Mt)tiul; <br /> til,car Valve(s'), ❑ shCar Valvc;(s). <br /> rl Dispenscl'('nntainment 11oat(s}and Chain(s). C3 DispcstscrCon(ninment Float(s}and C:hiin(+), <br /> Dispctiscr W. Dispenser Ill• <br /> ❑ Disnserr C'nntainn,enl Sests0r(s). Model; Q Dispenser C:ontainmenl Sensor(5)• Modci: <br /> ❑ tiltV tt Valve(5) ❑ `hcnr Voile(C). <br /> ❑ t)is}tcnsur Containit�ent bloat(s)atld Cliain(L). © 1)Fspensur Cantail,n,rnt Float(s)and Clain(s). <br /> "If the facility Contains more;tank:;or dispensc"s,coley this form,include inforillation for(:very tank and dispenser at the facillty <br /> C. Certification - I certify that tate cquiptnent identifted in this dncuutent iris inspected4erviced in acenrtlsutce with the <br /> tnanufuctuver's gtt-tdelines. Attache(%to this Certification is inrurmution(e.g,manufactures'checklists)neeessaly to verify that this <br /> iafermation is correct and a Plot flan$lsotving the laytrut of monitoring cgttipliient. For any egtlipment capable of generatinszsucit <br /> reltortS,l have also 4ttt0Ched a copy of the; r elseck oll drat nppt}}: ❑ SYSW111 set-up ❑ Alarm history report <br /> Technician Name(print): SSS-RonW Signature: Original on file at SSS <br /> Certification No.: 290-62-0068 License-N'o,; 485184 <br /> Testing Company Name: Ser. Sta. SYS• Phone No.; 408 971-2445 <br /> Site Address: 7910 Sacramento lid. (7 Hammer Lane Date ofTestiltg/Servicing: 11113103 <br />