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DEC-23-2004 12:47 SERUICE STATION SYSTEM 408 971 0135 P.03 Monitor* System Equipmenkertification For Use By All Jurisdictions Within The State of California Authority Cited., Chapter 67, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code ofRegulutions This form must be used to document testing and servicing of monitoring equipment.A separate certiScat-_gn or report must be prepared for each monitoring system control panel by the technician who pe'Ifonns 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 system within.10 days of test date. A. General Information Facility Name:99 Shell Bldg.No.: Site Address: 7700 Moreland Ct. @ Hwy, 99 City: Stockton, CA Zip: 95212 Facility Contact Person:' E"\f `U� Contact Phone No.: (209)957-5398 Make/Model of Monitoring System: V/R Simplicity Date of Testing/Servicing: 11 ID4� B. Inventory of Equipment Tested/Certified )4 /(A Cluck the appropriane boxes to indicate specific equipment hnspeeted/serviced: Tank ID;01- eau Tank ID: 02-Plus In-Tank Gauging Probe. Model: VR$47390-107 Tank Gauging Probe, Model: YR 847390-107 Annular Space or Vault Sensor. Model: VR 794340302 t%Annular',Pane or Vault Sensor. 'Model: VR 794380302 W/Piping Sump\Trench Sensor(s). Modcl: VR 784380-208 K Piping Sump\Trench Sensor(s). Model: VR 794380-208 0 Fill Sump Sensor(a). Model: None 0 Fill Sump Sensor(s). Model: None o Mechanical Line Leak Detector. Model: None Q Mechanical Line Leak Detector. Model: None Electronic Linc Leak Detector, Model: VR Sormi;8484 Flectmnic Line Leak Detector. Model: VR Series 8484 [] Tank Overfill\Nigh-Level Sensor. ':Model: None 0 Tank Overfill\High-Level Sensor. Model: None p Other(specify equipment type and model in Section Eon Page 2). Q Olhcr(specify equipmetit type and model in Section Pon Page 2). T'�Rk ID: 03-Prem Tank ID; 04-Waste Oil i-Tank auging Probe. el: VR 847390.107 Q In-Tank Gauging Probe. Model: None Annular Space or Vault Sensor. Model: VR 794380302 yAnnular Space or Vault Sensor, Model: VR 794390-420 Piping Sump\Trench Sensor(s). Model: VR 79380 4 -208 0 Piping Sump\Trench Scnsor(s). Model: None 0 Fill Sump Scnsor(s). Model: Non. O Fill Sump Sensor(s)_ Model; Non. _ (] Mechanical Linc Leak Detector, Model: Non• Q Mechanical Line Leak Detector, Model: None Electronic Line Leak Detector. Model; VR Series 8484 Q Electronic Linc Leak Detector, Model: None 0 Tank Overfill\High.t.evel Sensor. Model: None T ank Overfill 1 High-Level Sensor. ,Model: VR 794390.420 Q 011ier(specify equipment type and model in Section 1 on Page 2). !a Other(specify equipment type and model in Section F-on Page 2). Dispenser ID: 01-02Dispenser 1D: 03-04 Dispenser Containment Sensor(s). Mode: VR 794380-221 IklDispenser Containment Sensor(s). Model; VR 7[14390.321 Shear Valve(s), Shear Valve(s). Dispenser Containment Float(s)acid Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05-06 Dispenser ID: 07-08 l Dispenscr Containment Sensor s). del: VR 794380-''21 Dispcnscr Containment Sensor(s). Mode: VR 794380.321 X Shear Valve(s). shear Valve(s). I] Dispenser Containment Float(s)and Chain(s). C) Dispenser Containment Float(s)and Chain(s), Dispenser ID: Dispenser ID: 0 DispnrtserContainment Sensor(n). Model! 7 Q DispcnaerContananen[Srnsvr(s), ModcL ? 0 sheat'Valve(s). 0 Shcar Valve(s). C Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containmcnl Floal(s)and Chain(s). *Ifthc facility contains more tanks or dispensers,copy this form.Include inforzmtion for every tank and dispenser at the facility C. Certification- I 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 azul a Plot Plan showing the layout of monitoring equiplueut. For any equipment capable of generating such reports,I have also attached a copy of the; (check all theirapply).- Q System set-up Q Alar ' tory relic Technician Name(print):SSS-Tedi fly Signature: Certification No.: W6— b 5" p 11. 5 Ire License.No,"'485184 Testing Company Name:Ser. Sta. Sys. Phone No.: (408)979-2445 Site Address: 7700 Moreland Ct. @ Hwy. 99 Date of Testing/Servicing: P13 r