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04/23/2004 20:13 408971g;635 SSS INC PAGE 02 Monitoring s e Equipment rliotertificati on For(1se BV A 11Jurisdictions Within f f sfwhor•iCl-Cited: Chapter 6.7• Health and Safety Code; Chapter 16,Division 3, Title 23, CcrJifvrta.i.rr Code of Regulations This form must I)c used to document testing and servicing of monitoring equipment. A separate certification or r ort must be nrj enarM for each inytzitoring system control panel by the technician who perforans the work.A copy of this fol m must be provided to the tank system owner/Cfg.UserName. The ovmer/Cfg,UserName must subunit a copy of this form to the local agency regulating Us) witWin 30 days of test date. A. General Information Facility Nate: Country Club Sholl Bldg.No.: Site Address: 2575 Country Club Blvd.Q Plymouth City: Stockton, CA Zip: 95204 Facility Contact Person: zA04V, - Contact PhoneNu.; (209)948-0574 Make./Model of Monitoring Syste.tn: WIRSinnPliCitY Date ufTesting/Servicing: 3124104 113. Inventory of Equipment Tested/Certified Checic the appropriate I)oxes to Indicate spocirc cgtrtpment insputt'ed/Serviced: Tank ill'41 -Regu Tank 1D° 02-Prern ❑ In-Tank Gauging 131•obc. IVloilel: VR 047390-109 _ ❑ !n-Tank Gallgiflg Prclbe. MO(lel: VR 847390.709 VR nnular5)ace or Vault SCtlsor• Model: VR 794300.302 �].Iirv,�dar Space or Vault Scn5or. Modcl' I (� _Q—Piping Sump\Trench Sensor(s). Model: yR 794390.208 Piping Sump 1 Trench Sensor(s). Moocl: VK 0`a4seo•aos ❑ Fill SUmp Sensor(5)- Model! Nono ❑ Fill Sump Sensor(s). Model: None f1 vlechaniCal Line,Leak f)ctcctc». Moticl: None p Mechanical line Leal(Detector. Model Norte A-TiccntN11C.Lilir Leak Detector. Model; VR Series 8404 Icetronie Line 1..calc Detector, Model: YR 3udua 0404 ❑ Tank Ovcrl'ill\high-lxvcl Sensor, Model: None ❑ Tank Overfill\i-ligh•Levc1 Sensor. Model: gone �] Other(specify equipment 1'ypc and moilel itl Section E on Page'.). ® Other(specify equipment type and model in Section E on Page 2)- Tank D' 03-Waste ell FAP,,, ank(2ugi 16'Protn. Model: VR 347390.104 Gauging Probe, Model: lar Sparc ur Vault 30150I•, Modelo VR 7®4seo-1+e�' -3ey j ,pnrenr VaultSensor. Model: g SLIMp\TI-ClIC11 SCIIS01'(5)- Model: None ump\TI'ench Sensor(s), Mcxlol:. _ ump Sensor(S}, Model: None ❑ Pill Sump Sensor(5)- Model: uuie:al Line:Lcak 1.)cteccor. Medd: Nono _ p Mechanical line Lonk Detector. Model; tr•onic Linc l,.cak Detector. Model: Nono ❑ Electronic Line Lcak Dcteeaur. Model: Overfill\I•ligh-Leer]Sensor. Model: None _ Q "Tank Overfill\High-Level Sensor. Model: r(�pecffy cquipmrnt type and mprlol ire Section F.no page 2). ❑ Other(sped I'y equipment type and model in Section E on Page 2), 01-02 LD11penser ID' 03.04 l)iSpellmel'I.I)' -- „�"-f)ispensar Cuntainillrot Sensor(s), Model: VR 99d380.821 Dispenser oyer Containment Sensor(s). Model: VR 794380.321 ,Q-511"r VOM!(s). 5ncar Valve(s). ❑ Dispellser containmcnt Float(5)and Chain(s), Dispenser CQnlainmellt Float(5)and(.:pain(s). Uis�ctiser TD- 05-D6 Dispenser TT?° 07-0$ k VR79438032i_._ DiS cnscr Contait1111e11t Sensor(s). Model; VR 794380-32i .[J"Dispcnscr C'nnlainnl8ni Sensor W. Model',� .� P .Q"shear Valve(s), P-�hear Valve(s). ❑ r!ikpen rr Containment 1 lnsir(c)and Chain!,c). ❑ Di%penscr Containment Float(s)and Chain(s). Dispenser ID• Dispenser ID: (31)i;penser Containment Sensor(s) Model:_ ❑ i)ispense Cotttainmenl Sensor(5). Model: ❑ Shear valve(s). ❑ s114ar Vail,*(e), 13 l�i�pcnsu Containment}Moat(s)able C'ltsin(s), ❑ Dispenser containment Float(s)and chain(s), If the facility contains more tanks or dispensers.copy this form.hicludc inrornlatioll for every Lank and dispenser at the facility C. Certification— I certify that the equipment identiited in this document 1405 3115pected/serviced in accordance with the manut-acturet•'s guidelines. Attached to this Certification is information(e.9,Itlariulacturesr Qhecklicts nccesstrry to verify that this information is eor,rect and a Plat Plan Showing the layout of monitoring equipment. For aoy equ" Ment gable orgencrsl;' g such repurts.l have also attached a copy of the; (check all that applt): ❑ System set-up ❑ Alarr istory report / Technician.Na.lne(print): SSS-Ronal Signature: C el-tificAtion No.: 290-62-0088 License.No.: 485134 `resting Company Narne: Ser. Sta.S s. Phone No.: (408) 971-2445 Site Addreaa: 2575 Countg Club BIvr1. PI mouth Date of Testing/Se.rviciug: 3124104