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04/18f2003 08: 18 4@8971@ "� SSS INC PAGE 02
<br /> Monitorin system Equipmentertif i cati
<br /> For U.sa By.111 Jttr isrll�riurrs jf'irlrirr. T17e SIQILf L.
<br /> 'p ��
<br /> �tfljp fa
<br /> 4rrthp]'i1y Citcrrl, Chet tel'G.7, �fenlllr rind Suety Cor'le; Cliapler 16, Divisir�n.I• Tille 23tu, Ca1ifnrrlicr Cade of'REgulatiprrs
<br /> This foam muet be Lewd to docunncnt tL: [iug and selvicing of illortttoring eyuipnlent.A se agate cetTi t anon or x ort must be
<br /> rt aced l'or each monitoring=S Sterxl _coElti'Ol UarC61by the tcchtlician Who pOrforins the work- A COpy of this form must be provided
<br /> to the tank system owner/operator 'lie oNxmcr/Operator must submit a cc),y of this futtu to due local agency regulating UST systems
<br /> within 30 days of test date.
<br /> A. General in formation
<br /> Facility Nti,jme: Northside Shell
<br /> Site Address: 79'10 Sacramento Rd, Hammer Lane Bldg.No.,
<br /> City: Stocictorl, CA Zip: 95210
<br /> Facility Contact Person: Sael�dhu ("tlntnrt Phones No.: 209 472-T74$
<br /> Make/Model of.Monitoring System: V/R Simplicity
<br /> -- Date of Testi:ag,"Servicing: 0211110
<br /> S. Inventor=of Etluiipmentt Tested/Certifies)
<br /> Check theappropriate hoxes to indicate specific equipment inspe tecl/serv;ccd:
<br /> Tank ID:W -llegu
<br /> 2g [at-'Tank Gau•in•Probe, Tank rD' c2"Pius
<br /> .' vn 5673110.107 0g
<br /> !n.Tun Gatt in*Prohc,
<br /> N AnnularSpaccorVaultsensor, Model: VR 7943$0.302 5 b Model: VA 647390.10
<br /> iN Piping Skimp 1 Trench Scnsor(s), Q4 AnnuiB,r Space or Vault Scnsor. Madel: VR 79a38a30z
<br /> ( ) Model: VR 74a3Aa 353 hIc,near(c). h odul: Vit rsaiae•sss
<br /> U l�itl tiUrllp sensor(5), MadCI: None X PiPLSmp t Trench
<br /> Q Mechanical Line Leak Detector. Model: None ❑ Fill:iumpSetLsur(s), Model Bono
<br /> 131 t=:lcCtrotlic Linc Leak Detcator. Model; VR Scrlos Saes ❑ Mcchallical Line Leak Detector. Meadcl: Nona
<br /> ❑ Tank()vcl'1711 1 High-LeVel Sensor, Mnglel: None P9 Fltctronic Line:I.Cok Ratrrtnr. model: V17 Sgrlac 8484
<br /> ❑ f?C}ler(specify etluipn,ctll'type antf model irl Section 1 on Pa c W , ❑ rank Ovcrlill 1 liish-i.cvei Sensor. Mudel: none
<br /> S ) ❑ Othcr(Specify equipment type and model in Section E tin Page 2).
<br /> Ta21I<1171. 0 Prem
<br /> !$[ In- Tank Daubing Probe, Model: VRB47300-107
<br /> [auk IM u4-waste Oil
<br /> ® Annulal"Space or Vaull Sensor. M ❑ In-Tank Gauging Pre,hc. Madel; None
<br /> ndul; VR 704380.302 3 Annular tipaee Or Vault Sensor. Mode,; VR 7e4394.420
<br /> ® Pltrinb Sump S Trench Sctlsar{s;}. Muds;; vtt 9g4asa ss:
<br /> l7 ]•'ill Sum sensors . Q Piping Sump 1 l ltnch Sensor(s). Model: None
<br /> l+L c•� () Model; None ❑ hill Rrntilp Sensnr(s), ,M
<br /> L..I
<br /> Mechanical Line t.Cak Detector. f✓lo(iL"l. Nana odea: None
<br /> I$ F.'lcctronic bine Leak vrtmior. Model. VP—%orra9 s4e4 ❑ Mechanical Line Leak LXtcejor. Model: None
<br /> ❑ "!'talk 4vertilf'+I Ilgil Level Sensor. Madel. None ❑ Ltuvkwuic Linc Leal:Detector, Model: Nana
<br /> ❑ 011,er(specify equipnterlt type and mLxirl in Sectionti an pate 2). C5 Tank Uvertill V I-ilgh-LIVCI Scnsor, Model: VR 7943$0420
<br /> 0 Other(specify equipment type and ttlodel in SCctiorl L on Page 2).
<br /> Dispenser ID• 01•01!
<br /> M DispunSCrCc]rSCainmcntSerlsur(.$). MOdel: ®vaL,ereu406 Dispenser IT),- 03-04
<br /> fS Shear Valve(s). -- IN Dispenser t'or,lanlment Scnsor'(s)- Model: ge�udreuaaB
<br /> © niap,:i,acr C'untUinmen,Float(s)and t:naln(s). 3 Shear Valve(s),
<br /> ❑ Divpenscr C'untrlinn edit Float(s)and Chain(5),
<br /> Dispenser To; 08-06
<br /> MuriDispenser ID;
<br /> [)i$pe3YlCI`(�pntalnmentSCn60r(y}. el• F3caurlrairanrw ❑ Cl'sspcnst� Cl�rslainmenSSCItsOY
<br /> 09 Shcar Valve(5). Ib). ivlodel:
<br /> Valve( ).
<br /> t] D;snenser Cunlanmetlt Flout(s)and Chain(s). [3 Shear
<br /> ❑ Dispenser Containment Float(s)and Chain(s).
<br /> Dispenses-I,U•
<br /> ❑ Dispenser CL3ntainnlCllC Scnsor(S), Marie), Dispenser.I.D-
<br /> ❑ Shcar valve(s), a Dispenser Containment Sensor(s)- Madel;
<br /> ❑ F)kpf-nsrr f em Ujinnignt Flout [1Shear Valve(s).
<br /> (-)and Chain(s). LI r.alspenscr CantainrnmL Float(s)and Cllain(s).
<br /> *Iftl,e facility contains more tank$or d ispcnsers,copy this Fortin.include information for`every tar)k and dispenser ut the Facility
<br /> C. Cel-tiliC210011- l Certily that the equipment identified in this docnnlenl vrah in5pcelcd/servlced in accordance with the
<br /> mauuracturer"s guidetineS- Attached to this Cortit-rcatiun is information(e,g.Manufactures'checklists)necessnry to verlfv that this
<br /> infat9natil,n is correct an4J a Plot Plan showing the layn rt nr monitortrIg Qg{eiomcnt. For any equipment cairahlc of generating curl,
<br /> reports.I have also attaelted a copy of the-, (r/reek 411 tkar apply). ❑ System set-up ❑ Alarm history report
<br /> Tee.h,•rir.iatn Na„-lc(print):SSS-Chris
<br /> Signature: Original an file at SSS
<br /> Certification No,; 566-05-8259 ”
<br /> License, No.; 4651$4
<br /> Tasting Company Natuc. Ser. ata. Sys.
<br /> Site Address: 7810 Sacratrmento Rd. Hammer Lane I'h.oneNo.; 40$ 971-2445
<br /> Date of Testizng/Servicing: 02/19143
<br />
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