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� 04f1812002 17:34 408971 W SSS INC # PAGE 02 Monitoring system Erertification cuipxnent For Use By Ali Jurisdictions Pfithin The State of Caiif©rnia Authority Cited_ Chapter 6.7,Healrh and Safety Corte: Chapter 76, Division 3, Ptle 23, California Corte of Regulations This form must be aged to document testing and servicing of mo0toring equipment.A separate certification or report must be prepared for each ml)laitOling System control panelby the technician who performs the work.A copy of this form must be provided to the tank system ownerloperator. The owner/operator must submit a copy of this form to the local agency regulating UST sys(cuts within 34 days of test date. A. General Information Facility Name:Shell Manteca Bldg_No.; Site Addresa: 1071 N. Malin St. @ Louise City; Manteca, CA Zip: 95336 Facility Contact person: Diana Contact Phone No; (209) 823-5265 Make/Model of Monitoring System; Veeder Root$im Ilei Date of Testing/Servicing: 03119102 B. Inventory of Equipment T'estedlCertif;ed Check the appropriate boxes to indicate specific equipment inspected/serviced: T ank 07 ite®alar 71Sg; 02-Pramiurn 99 Gauging ProUc. Model:_YR 847390-109 k Gauging Probc. Model; VR 847300.109 $pack or Vault SensorModal: vR 744Saosaz r 5pacc in 1/oult Sensor, Model: 79a3ao•sox mp\Tn nch SensUr(5}, Mut4c1. vn 7eaonv�no Smp 1 Trench Sonco�(-.) Madel: uA79n7Aoana Sensor(s), Model: None Sensor(s). Madel: Nana _ cat Linc Leak Detector, Model: Nona ❑ Mechanical Line Leak Detector. Model: None c Mechanical Linc Lcak DeLe t Modcl: vR 7�iaoa-oot py Slcctronic Line Leak Detector. Model.vR 391196-D01 ❑ Tank Ovcrtill 1 High-Level Sensor. Modcl - None ❑ Tank Overfill 11 filth-Level Scnsar. vtodeh None ❑ Otlicr(specify equipment type and lnodnl in Section E on Page 2). ❑ Other(specify cquipmcnt type and model in Section Eon Page }. Tank ID ®3-Waste Oil TankID: In-Tank{iauging Probe. Modcl: None ❑ In-Tank Gauging Prot+c. Model; ? N :Annular 5pacc or vault Sensor, Model: VR 794390-0a0 O Annular Space or Vault Sensor. Madel: ? 0 Piping Sump 1 Trench Sensor(s). Model; Nona ❑ Piping Sump 1 Trcnch Sensor(s), Modcl: ? 0 Fill Sump Sensor(s). tvladcl: None ❑ Pill Sump Sensor(s)- Model: ? 1I] Mccbani cal Linc Leak Detector, Model: Non. ❑ Mechanical Linc Lcak Detector_ Model: ? ❑ Electronic Linc Lcak Detector. Model: None p Electronic Line LeaK ui:tecter. mode[: T N 'tank overfill l High-Level Scnsor. Model! VR 794394-429 ❑ Tank Overfill 114igb-Level Sensor, Modcl;. ? - ❑ Other(specify equipment typt and model in Section E on page 2). ❑ Othcr�(b.pecify equipment type and model in Section E an Page 2), Dispenser YD' 01-02 Dispenser ID- 03-04 Dispenser Containment Sensor(s). lvl0del: YR7943e0.322 Q9 LlispenscrContainment Scnaor(s) Model, VR7943e9 922 ® SSllepr Valve(c). Co Shr.or VnlvP(c). D Dispenser Containment Float(s);find Chain(s). ❑ Dispcnscr Containment Float(s)and Chain(s), Dispenser ID 05-os Dispenser XD- 07-08 Dispenser Containment Sensor(s). Model: VRYB4340.3z2 Pq Luispcnscr C:ontainmcnt Sensor(s}. vtooel, vRrBasaa-azz g Shear Valve(s). ® Shear Valve(s}. ❑ Dispenser Contasnmeni Float(s)and Chain(s). _ ❑ Dispenser Containment Float(s)and Chain(s), Dispenser ID• Dispenser ID- � Dispenser Containment Senbor{s}. ivlodei; ❑ DispcnscT Containment Sensor(s), M06c17. M Shear Valve(s), Li Shear Valve ❑ Dispenser Containment Float(s)and Chain(s}. C] C3ispcnser Containment Float(s)and Chain(s)- 'lfthc facility contains more tanks or dispensers,copy this form,Include information for every tank and dispenser at tho facility C. Certification- I certify that the equipment identified in this document was inspected/serviced in accordance with the man facturer,&guidelines. Attached to this Certification is information(e.g.manufactures'chctklists)necessary to verity that this infor atfon Is correct and a Plot Plan showing the layout ormonitoring equipment. For any equfpmrrtt cat:nbtr of gcurrnti„R Koch reports,(have also attached a copy of the, (creek all that apply): I] System set-up ❑ Alarm history report 'IecluliC an Name(print):SSS-Rots W. Signature: original on file at SSS Certifie Tion No,: 290.62.0088 License.No.: 485184 Testing ompany Name: Ser. Ma. Sys. Phone No.' (408) 971-2445 Site Ad cess: 1071 N. Mair[ St Louisa Date of To sting/Sery icing: 03119102