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04/23/2004 20:13 4089710 35 SSS INC PAGE 03 <br /> Monitoring System i Pertification <br /> For'Cls(�fay 411 Jatric(lictions Within The State of'Ccrlffbrnica <br /> Alith07 itY Cited.- Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California ni(a Code of Regulations <br /> This form must be used to document testing and servicing of txtonitoring equipment. A separate certification or report must be <br /> prepared for each monito1'r!).g system control panct by the technician who performs the work.A copy of this form must be provided <br /> to Ole tank system owner/Cf�T.UserName, The owner/Ct,UserName must submit a copy of this fonn to the local agency regulating UST <br /> within 30 clays of Lest date. <br /> A. General Information <br /> Facility Ntayk,o: C Guntry Club Shell Bldg.No.: <br /> Site Address: 2575 CountrV Club Blvd. & Plymouth City: Stockton, CA Zip: 95204 <br /> Facility Contact Person: Susan CWttncl Plluizc No.: (200)948-0574 <br /> Make/Model of:Monitorintg System: V/R Simplicity Date of Testing/Servicing: 3124104 <br /> 13, Inventory of Equipment Tested/Certified <br /> (:batik the apprnpriatt boxes to indicate,pecific equipment inspected/serviced: <br /> Tani:IT)•01 -Regu Tank ID 02-Prem <br /> ❑ In-'funk Cauiging Probe. Model: VR 847390.109 ❑ in-Tank Gauging Probe. Modcl: VR 847.390.104 <br /> M Annular Spacc or Vatllt Sensor• MO(lel: VR 794380.302 N Annular',Pace or Vault Sensor. Model: A 794380-302 <br /> 4 Piping SUnlp vrrc lch Sensor W. Modcl: VR 794380.208 N Piping Slntlp.t Trench Sensor(s). Modcl: VR 794380.206 <br /> ❑ Pill Sun,p Scnsol'(5). 1vinrlcl: None 0 Fill Sump Sensol'(S). Model: None <br /> ❑ Mechanical Line Lcak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: No— <br /> (� Ficcirnnic Line I_enk Detector. Model: VR Series 8484 LleCironiC Line Leak Detecior. Model: VR Sen Ma a404 <br /> ❑ Tunk Overfill 1 hli�;h-Level Sensor. Mendel; None ❑ Tank Overfill\I-tigh-Level Sensor. Model: None <br /> ❑ Other(specify equipnlenl type and model in Section is on Page 2). ❑ Other(spceify equipment type and mudel in Section E on Page 2). <br /> Tank 1D- 03-Wastc Oil Tunic ID• <br /> ❑ in• rank onlrging Probe. Madel: VR 647390.104 ❑ In-Tank Gauging Pt,)bc. Model: <br /> ® AIMLA 1lipacoorVatllt'icn.ncw. Model VR 794380-S0, ❑ Annul;,r4prrenrV! ltSensor. Model' <br /> ❑ Piping SUMP\l'rcnch Sensor W. lvindel: None ❑ Piping Sump\Trench Sensor(s). Model: <br /> ❑ Fill Sump Sensor(s). Model: None - ❑ Fill sump Sensor(S). Model: <br /> Q %1cchunival Line Lcak I:htcutor. lvlodcl- None ❑ Mechanical Line Leak Detector, Model: <br /> ❑ hlecironic Line Leal(Detector, Mcrilel: Nono ❑ Electronic Line Leak 1.)ctector. Modc1: <br /> ❑ 'rank OwrliII\IIigh-l.evcl Sell sor. Model: None _ ❑ Tank Overfill'%High-Level Sensor, Maicl: _ <br /> ❑ i hhrr(cntarify rrluipment type and model in Section E on 113ac 2), 0 Other(specify equipment type and model in Section E on Page 2). <br /> Dispenser TD: 01.02 Dispenser.LD• 03.04 <br /> a Dispniscr('oilIainment Sensor(S). Model: vR 794380.341 IN Dispenser Coll taill nienl Sensor(5)- Model: VR 794380.321 <br /> Ij Shear Valve(s). a Shear valve(s). <br /> (j ni<pcnscr C'unlainnlel1t I^lost(s)and Chain(3). 0 Dispenser Containment Float(5)and Chain(s). <br /> Dispcnvcr 113. 05.[16 Dispen4pr I'll- 07-0$ 111­ <br /> 29Dispt:nscr Cunl:tinmcru Bonsor(s). Model: VR 794360•321 <br /> (g Dispenser C'ontainnxnt Sensor(s). Model: vR794380•321 <br /> IN Shear Val'c(S), ® Shear Valve(s). <br /> ❑ niyion,;,w('nnrainment i treat(S)and Chaffin(S), ❑ Dispenser Containment Hout(ti)and Chain(s). <br /> Dispenser-]D-.-, Dispenser IM, <br /> ❑ f)isPensur C"untainment Se n5or(s). Model: d Dispenser Cnntuutnleltl SctlsOf(5). Model: <br /> L Shcor valve(s). ❑ S'honr Vrilvc(;). <br /> Q Dispcnsrr('ontainnlent I'lout is}and Chant(s), ❑ Dispenser C'ontainnicrtt Float(s)and Chain(s). <br /> *IPtire facility Contain:more tanks or dispensers,copy this Form.Include in'rormation Tor every tank and dispenser at the fOCility <br /> C. Certification- I certify that the equipment identified in this document was inspectors/serviced in accordance with the <br /> manufacturer's guidelines. Atlaehed to this Certification is information(e.g.manufactures'checklists)necessary to verify that this <br /> informatiotl is correct and a Plat Plan 1110%ving the layout of monitoring equipment. Icor any equiptttent capable of gencrating well <br /> reporth. I have alsn attached a copy of the; (check all thal appl): ❑ S)•stent set-op D Alarm history report <br /> '1'echnicia.11 Name(print) SSS-RonW Signature: Original on file at SSS <br /> Cc.rtitiea.tion.No.: 290-62-0088 License.No.: 485184 <br /> Tenon);Cottlpany Name: Ser.Sta. SyS. Phone No.: (408)971-2445 <br /> Situ Address: 2575 C min"Club Blvd a Plymouth hate of Testing/Serviciniz: 3124/04 <br />