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MonitorinipSystem EquipmentOertircation Fur use By All Jurisdictions Within The State of Cali ornia 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 panelby the technician who performs 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 systems within 30 days of test date. A. General Information Facility Name: Shell 136139 Bldg.No.: Site Address: 7910 Sacramento Rd. @ Hammer Lane City: Stockton, CA Zip: 95210 Facility Contact Person: Singh Contact Phone No.: 209 472-7748 Make/Model of Monitoring System: Veeder Root Simplicity Date of Testing/Servicing: 01125102 B. Inventory of Equipment Tested/Certified i Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:01 Regular Tank ID 02'Plus 5 in-Tank Gauging Probe. Model: VR 847390.107 QQ In-Tank Gauging Probe. Model: VR 797380-107 Z Annular Space or Vault Sensor. Model: VR 794380.302 Q9 Annular Space or Vault Sensor. Model: VR 794380.302 Q Piping Sump Trench Sensor(s). Model: VR 794370-352 N Piping Sump 1 Trench Sensor(s). Model: VR 794380452 ❑ Fill Sump Sensor(s). Model: None ❑ Fill Sump Sensor(s). Model: None ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None Q9 Electronic Line Leak Detector. Model: VR 331198-001 Q9 Electronic Line Leak Detector. Model: VR 331197.001 (] Tank Overfill\High-Level Sensor. Model: None ❑ Tank Overfill 1 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 Premium Tank ID 04-waste til 3 In-Tank Gauging Probe. Model: VR 847390-107 [1 In-Tank Gauging Probe. Model: None I@ Annular Space or Vault Sensor. Model: VR 794380.302 Qq Annular Space or Vault Sensor. Model: VR 794390 429 ® Piping Sump Trench Sensor(s). Model: VR 794380-352 p Piping Sump,Trench Sensor(s). Model: None ❑ Fill Sump Sensor(s). Model: None L7 Fill Sump Sensor(s). Model: None i ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None Electronic Line Leak Detector. ModemVR 331198.001 ❑ Electronic Line Leak Detector. Model: None ❑ Tank Overfill\High-Level Sensor. Model: None Tank Overfill 1 High-Level Sensor. Model: VR 79439D-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 Dispenser Containment Sensor(s). Model: Beaudreu 406 M Dispenser Containment Sensor(s). Model: seaudreu 406 Q9 Shear Valve(s). Q4 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID- 05-06 Dispenser ID' M Dispenser Containment Sensor(s). Model: 6eaudreu 406 p Dispenser Containment Sensor(s). Model: i 0 Shear)Valve(s}_ _ ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID- Dispenser ID• ❑ Dispenser Containment Sensor(s). Model: [I Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). p Shear Valve(s). II 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. Certifleation- 1 certify that the equipment identified in this document was inspected/serviced 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, (checA all that appf}y: ❑ System set-up ❑ Alarm history report Technician Name(print): SSS-Ron W. Signature: Original on file at SSS Certification No.: 290-62-0088 License.No.: 485184 Testing Company Name: Ser. Sta. SYS. Phone No.: (408) 971-2445 Site Address: 7910 Sacramento Rd. @ Hammer Lane Date of Testing/Seryicing: 01125/02