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04/19/2002 14:03 408971 SSS INC PAGE 02 Monitoring System a icia For Use By All Jurisdictions Within The State of C.'alybrnia Authority Cited: Chapter 6.7, Health and Safety 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 re aced far each monitorin s steno contra! panelby the technician who performs 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 Lu tiro lvuai agency regulating UST systerns within 30 days of test date. A. General Information Facility Name: Shell 136144 Bldg. No. - Site Address: 2575 Count Club Blvd, @ Plymouth City: Stockton, CA —zip: 95204 Fatality Comm t Person: Steve Contact Phone No.: (209) 948.0574 Make/Model of Monitoring System: Veeder Root Simplicity Date of Testing/Servicing: 03/19/02 B, Inventory of Equipment Tested/Certified Cheek the a ro riate boxes to indicate specific equipment inspectediservieed: I'll p Tank ID• ®l -Regular Turk ID- t)2 -Premium 29 in -Tank Gauging Probe. Model; VR 847890.109 N In - Tank Gauging Probe. Model: VR 847399-149 PQ Annular Space or Vault Sensor. ModCL VR 79438a.302 18 Annular Space or Vault Sensor. Modrl: VR 794330.392 _ l4 Piping Sump \ Trench Sr WUL (n). Iviud0L VR 704280-20e C§ Piping Sump \ Trench $moor (r). Model: VR 794380.298 D Fill Sump Sensor (s). Model: clone ❑ Fill Sump Sensor (s)- Model: None ❑ Mechanical Linc Leak Detector. Model: None ❑ Mcehanicil¢ Line Leak Detector. Model: None Q9 Eltt-ttutric Laic Leak Detector. Model: VR291496-001Mverroaic Line Leak Det"Mr Mndele VR 331798-091 ❑ Tank Overfill \ High -Level Sensor, Model: None ❑ Tank Overfill \ High -Level Sensor. Modcl: Norte ❑ Other ( specify equipment type and modcl in Section E on Page 2). p Other ( specify equipment type and model in Section E on Page 2). Tank ID- 03 -Waste Oil Tank iD- ❑ in - Tank Gauging Probe. Model: Now p In - Tank Gauging Probe. Model; 9 I& Annular Space or Vault Sensor, Model: VR 794380.301 ❑ Annular Space or Vault Sensor. Model; 7 Q Piping Sump \ Trench Sensor (s). Model: None ❑ Piping Sump \'french Sensor (s), Modci: r ❑ Fill Sump Sensor (s). Model: None ❑ Fill Sump Sensor (s). Model: ? ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Linc Leak Octector. Model: ? Q EIectronic Line Ixak Detector. Model: None ❑ Llectronic One Leak Detector. Model: 7 ❑ Tank Overfill \ High -Level Sensor, Madel: None ❑ Tank Overfill \ High -Level Scnsor. Model: ? ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ Other ( specify equipment type and model in Section I. on Page 2). Dispenser ID,• 09.02 Dispenser 111; 03-04 ® Dispenser Containment Sensor (3). Model: VR 794394.521 Q9 Dispcn5cr Containment Sensor (S), Model: VR 794380.321 p9 shear velve ('a). 09 Shear Valvc (s). ❑ Dispenser Containment PloaL (s) and Chain (5). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID- M-06 Dispenser TD- 07.08 0 Dispenser Containment Sensor (s). Model: VR 7543110-M Q9 Dispenser Containment Sensor (s), ivluticl. VR 70441eo-591 11 Shear Valve (s). 0 Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s)- ❑ Dispenser Containment Float (s) and Chain (s), Dispenser ID' Dispenser ID. ❑ Dispcnscr Containment Scissor (s). Model: Q Dispenser Containment Sensor (s). Model: n Shear Valve fs.). ❑ Shear Valve W. p Dispcn5cr Containment Float (s) and Chain (s), p Di5pon5er Containment Float (s) and Chain (s), *if the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility C. Certification - I certify that the equipment identified ill this document was inspectediserviced 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 anti a Plat Plan showing The layout ormonitoring ettuiptuaut. Pot atey equipment capable of geacrating such reports, I have also attached a copy of the; ( check all tl:a1 apply): ❑ System set-up ❑ Alarm history report Technician Name (print): SSS -Ran W. _ Signature: Orl lnal on file at SSS Certification No.: 290-62-0088 Liccnbc. No.: 405184 Testing Company Name: Ser, Sta. Sys. _ Phone No.: 408 971-2445 Site Address: 2575 Countr Club Blvd. @ Plymouth Date of'lesting/Servicing: 03/19/02