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04/14/2004 07:49 4089710135 SSS INC PAGE 02 Monitorin?System Equipment fertif cation For Use By All Jurisdictions Within The Stare of California Authority Cited: Chapter 6.7. Health and St feiy 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 oanel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owller/operatot must submit a copy of this iorm to the local agency regulating UST system within 30 days of test date, A. General Information Facility Name: Main Street Shell Bldg.No.: Sitz:Address: 1071 N. Main St. P Louise City: Manteca, CA Zip: 95336 Facility Contact Pcrsuta, Kris Contact Phonc No.: (209)823-5265 _ Make/Model of Monitoring System: VIR Simplicity Date of Testing/Servicing: 3/22104 D. Inventor'of Equipment Tested/Certified Check the apprupriate boxes to indicate specific equipment inspected/serviced: Fank '07•Regu Tank in. uz•Prem nk GouingProbe. Model: VR147390d09 ❑ In- lank Gauging Probe. Model: VR847310,101 ar$pacC or Vaul[$onsof. Model: VR 794380.30] jg Annplar$pace 0r Vault Senior. Model: VR 794390.102 Jump•. l rcnch,sensor(s). Model: yn'54550-eon Q9 Piping 5timp l TrinICil Senior(s) Model: vR 754160.209 mp Sensor W. Model' None ❑ H11 Sump Sensor(s). Model: Nona nical Linc Leak Detector. Model: Notre ❑ Mechanical Line Leak Detector. Model: None nic Line Leak Detecwr. Model. VR a,,,w,coca I5 tlueno,dL Linc Lein,Daineo, Mvd01. Vn M0409101 verfill\High-Level Sensor. Model: None ❑ Tank Overfill\High-l-evel Sensor. Model: Nana ❑ Other(specify equipment type and model in Section E on Page 2). ❑ other(specify equipment type and model io Section E on Page 2). Tank ID' 03-Waste 011 TanklD- p In-Tank Gauging Probe, Model: None ❑ in-Tank Gouging Probe. Model: t ® Annnllr SpnOe or Vmnt Scnsnr- Model: VR 794390420 ❑ Ann alar Soace or Vault Sensor. Model: ? ❑ Piping Sump\'I"rcnch Sensor(s). Model: None ❑ Piping Sump\Trench Sensor W. Model: ? ❑ Fill Sump Sensor(s), Model: Norm ❑ Pill Sump Sensor(s), Model: t ❑ Mechanical Line Leak Detector. Model: No.. ❑ Mechanical Line Leak Detector, Model: ? ❑ PJectrtmic Line Leak Detector. Model: None ❑ Electronic Linc teak Detector. Model: ? N Panic overfill\High-Lwd Sensor. Model: VR 794310420 ❑ Tank Overfill\lligh•Level Sensor. Model: ? ❑ Odter(spoeify equipment type and model in Section E on Page 2). ❑ Other(liccify equipment type and model in Section P on Page 2). Dispenser ID 01.027ChliT) _ Dispenser ID' 03.04 DepenserContainmentSen ; yR 794310.322 Dispenser Containment Sensor(s). Model: VR794389.33399 Shear Valve(s). M Shcar Valve(s).❑ Dispenser Centainmcnt Floa ). ❑ Dispcnscr Containment Float(s)and Chain(s)F r .06Dispenser ID: 07-08s9n[Sen : vR 794150,= 09 Dispeheer ser Com.inment Sensor(s). Model: vR7saaeaa2z ulve ts).scr C'onmimnent flous). ❑ Dispcnscr Containment Float(s)and Chain(s). er lD' Aspenser ID: C) sur Containment Sensor(s). Modck ? ❑ Dispenser Containment Sensor(s), Model: VO ❑ Shear Valvc(s). scr Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). vlf the fseility contains more tanks or dispensers,copy this form.Include info=tion for every tank and disptmser at the facility C, Certification- I certify that the equipment identified in thin document was inspected/serviced In accordance with the manufacturer's guidelines. Attached to this Cerlilieatioa is Infoenatlon(e.g.manufactures'checklists)necessary to verifv that this information Is correct and a Plat 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-RonW Signature: Certification No.: 290.62-0088 License.No.: 485184 Testin.- Company Name: Ser Sta. Sys Phone No.: (408)971-2445 Site Address: 1071 N Main St 0 Louise Date of Testinp)Servicing: 3122104