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'Ionitorin System Equipment isertification For Use By till Jurisdictions Within The State of Calijornrra Authority Cited: Chapter 6.7, Health and Safety Corte; 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 tnonitorine system control pane by the technician who performs the work.A copy of this form must be provided to the tank system owner/Cfg.UserName. The owner/Cfg.UscrNarne must submit a copy of this form to the local agency regulating UST s within 30 days of test date. A. General Information Facility Name: Main Street Shell Bldg.No.: Site Address: 1071 N. Main St. @ Louise City: Manteca, CA Zip: 95336 Facility Contact Person: Jane Contact Phone No.: (209) 823-5265 Make/Model of Monitoring System: VIR Simplicity Date of Testing/Servicing: 03119/03 B. Inventory of Equipment Tested/Certified Check the appropriate hoes to indicate specific equipment inspected/serviced: Tank ID•01 _ egU Tank ID: 02-Prem QJ In-Tank Gauging Probe. Model: VR 847390.109 Q4 In- rank Gauging Probe, Model: VR 847390.109 gg Annular Space of Vault Sensor. Model: VR 794380.302 Q9 Annular Space or Vault Sensor. Model: VR 794380.302 N Piping Sump 1 Trench Sensor(s). Model: VR 794300.208 Q4 Piping Sump 1 Trench Sensor(s). Model: VR 794380-208 ❑ Fill Sump Sensor(s). Model: None ❑ Fill Sump Sensor(s). Model: Hone ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None Ug Electronic Line Leak Detector. Model: VR Series 8484 Electronic Line Leak Detector. Model: VR Series 8484 ❑ Tank Overfill 1 High-Level Sensor. Model: None ❑ Tank Overfill 1 Iligh-Level Sensor. Model: Nona ❑ Other(specify equipment type and model in Section L-on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID• 03-Waste Oil Tank ID• ❑ in-Tank Gauging Probe. Model: None p in-Tank Gauging Probe. Model: ? M Annular Space or Vault Sensor. Modck VR 794390.420 ❑ Annular Space or Vault Sensor. Model: ? ❑ Piping Sump\Trench Sensor(s). Model: None ❑ Piping Sump 1 Trench Sensor(s). Model: ? ❑ Fill Sump Sensor(s). Model: None ❑ FiII Sump Sensor(s). Model: ? ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: ? ❑ Electronic Line Leak Detector. Model: None ❑ Electronic Line Leak Detector. Model: ? Tank Overfill%High-Level Sensor. Model: VR 794390.420 ❑ Tank Overfill 1 High-Level Sensor. Model: ? ❑ Other( specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section L on Page 2). Dispenser ID 01-02 Dispenser ID• 03-04 og Dispenser Containment Sensor(s). Model: uR 794380.322 Q9 Dispenser Containment Sensor(s). Model: VR 794380.322 Qq Shear Valve(s). Q9 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID• 05-06 Dispenser ID- 07-08 Z Dispenser Containment Sensor(s). Model: VR 794380.322 Q9 Dispenser Containment Sensor(s). Model: VR 794380.322 (� Shear Valve(s). 5 Shear Valve(s). ❑ Dispenser C'ortaintttent Float(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: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain W. ❑ Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form.Include inlbrmalion for every tank and dispenser at the facility C. Certification- I certify that the equipment identified in this docurnent was inspected/serviced in accordance with the ilia nufit cturer's guidelines. Attached to this Certification is inforrnatiou(e.g.ma ill ractures'checklists)necessary to verify that this information 1s correct and a Plot Plan showing lice layout of monitoring equipment. For any equipment capable of generating such reports,t have also attached a coapt•of tile: (check alt that apply): ❑ System set-up ❑ Alarm history report Technician Name(print}: SSS-RhomeD Signature: original on file at SSS Certification No.: 561 77 3083 License.No.: 485184 Testing Company Name: Ser. Sta. Sys. Phone No.: 408) 971-2445 Site Address: 1071 N Main St @ Louise Date of Testing/Servicing: 03119103