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04/16/2003 16:13 40897 SSS INC PAGE 02 Monitor i11, System Equip ent rti ca ion Fe)r Use-, By Ali,lurixdictions Within the State of California Aurhnrio, Cited: Chopler 6.7. Health and S*ty Code: 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 tp ,epared'for each moll itorin 7 S stem control �anelby the technician who perforins the: work. A copy of this form must be provided to the tank system owner•/C%,UserNamc. The owner/C(g.UserName must Submit a copy of this form to the local agency regulating UST s, within 30 days of test date, A. General.inft)rmation Facility Name: Shell 136144 Bldg. No.: Site Address: 2575 Country Club Blvd. a Plymouth City; Stockton, CA —zip, 95204 Facility Contact Person; Tammy Contact Phone NO.: (209) 948-0574 Make/Model of Monitoring System: VIR Simplicity Date of Testing/Servicing: 03119/03 B. Inventory of Equipment Tested/Certified Cheek the annronriate boxes to indicate specific equiptnent inspected/scrvieed: Tank ID; 01 Regu Tank IDL02 - Prem M In - Tank Gauging, Probe, Model: VR 847390.109 IN in - Tank Gauging Probe. MtAel; VR 847990.109 IN Annular Space or Vault Sensor. Modcl: VR794380,302 N Annular SpaCC or Vault Sensor, Modcl: VR 794380-302 IN Piping, Sump \'flash Sensor (5). Model: vR 744280.208 ® riping bump \ Titilcll Sensor W. Model: VK "030-200, Li Fill Sump Sensor (s). Model: None ❑ hill Sump Sensor (S). Model; None ❑ Mechanical l..ine. Leak Detector. Model' None ❑ Mechanical Line Leak Docclor. Model: None C9 Electronic Linc beak Detector. Moocl: vn genes 0464 05 Elucavi is hiuG Ixuk DettcLur, ivlodct: yri ger oa eaal Q 'rank Overfill \ Fligh-Level Sensor. Model; None 0 'funk Overfill \ High-l,.cvel Sensor. Model: None ❑ Other ( specify equipment type incl model in Section E on Page 2). ❑ Other ( specify cquipment type and model in SCction E on Page 2), Tank ID• 03 - Waste Oil Tank IDL ❑ in -'tank Gauging Probe, Model; Nano ❑ in -'rank Gauging Probc, Model: ? Annular Space 01,'•1atllt sen%: )r. Tvtodcl: VR 794380301 ❑ Annular Spaec or Vault $en5or. hlodel; ? ❑ Piping Sump \ Trench Sensor (5), Modcl: None ❑ Piping Sump VI"rcnch Sensor (S). Model; ? t3 Fill Sump Sensor (S). Model; Nona ❑ Fill Sump Sensor (s). Model: 7 ❑ .Mechanic;,[ 1, inr t nak DMenint. Model: None ❑ Mechanical Linc Leak Detector, Modcl: ? ❑ C-lectronic Line Lcalc Detector. Model: None p hieetronie Line Leak nctcctor. Model; 7 ❑ Tank Overfill \ I-ligh•Levcl Scnsor. Model: Kone T2nI( (liverfitl \ High -Level Sensor, Modcl: 7 ❑ Other ( specify equipitlent type and model in Section E on Page 2). ❑ Othcr ( specify equipment type and model in Section C un Page 2). Dispenser CD' 01-02 Dispenser Ill• 03-04 ® Dispenser Containment Sensor' (s). Model: VR 794380.321 C9 Dispenser Containment Scnsor (s), Model: NR 794380-321 Shear Valve (S), 29 °3h4ar Vulvc (3). ❑ Dispenser Containment Float (S) and Chain W. ❑ Dispenser Containment Float (s) and Chain (s), Dispenser ID• 05.06 Dispenser ID: 07-08 pg DiepenserContaintnent.Scnsor(s). Model; VR 794380-321 IN L)Igxii.crC'ontainmentSensor(s), Model: VR794350.321 lig Shear Valve (9). N Shear Valvc (s). ❑ Dispenser Contaim„ent Float (s) and Chain (s), 0 Disjwnser Containment Float (s) and Chain (s). Dispenser 1D• Dispenser IDS ❑ Di5pCn5er Containment Sensor (s). Model: ❑ Dispenser Containment SSel1sor (5). Modcl: 0 :Shear Valvc (a), D Shear Valve (e} ❑ Dispenser Containment Float (s) and Chain (s). 0 Dispenser Contafnnienl Float (s) and Chain (s). *If the facility contains mono tanks or dispensers, copy this form. Include information ibr every Lank 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' eheeklWs ) acmessary to verily that this information is correct and a Plot Platt showing the layout of monitoring equipment. For Any equipment capable of generating such reports, I have also Attached 3 copy ofthc; (e'heekall that apply); ❑ System set-up ❑ Abirmhistory report Technician Name (print): SSS-RhomeD Signature: Original on file at SSS Certification No.: 561 77 3083 License. No.: 485104 Testing Company Nance: Ser. Sta, Sys., Phone No.: (408) 971-2445 Site Address; 2575 Country Club Blvd. a Plymouth Date of Testing/ServichiX 03/19/03 _