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,a4/26/2004 14:23 4089710125 SSS INC PAGE 02 y is is _ It rl St t Certification For Use By All Jurisdictions Within The State of California 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 gggarate certification or re rt roust be poi each monitnri eyctern cslntr by the technician who Performs the work. A copy of this form must be provided pregared to the tank system owner/Cfg.UserName_ The owner/Cfg_UserName must submit a copy of this form W the local agency regulating UST within 30 days of test date. A. Generallnformation facility Name Trac Blvd Sktafl &Mini Mar#, R1Ag. Nn.: Site Address: 3725 N. Tracy Blvd. Q 1-205 _ City: Tracy, CA Zip: 95376 Facility Contact Person Uontact Phone No.: (2091835-7608 Make/Model of Monitoring System.: V/R Simplicity Date of Testing/Servicing: 3131104 S. Inventory of Equipment Tested/Certified Check the appro riate boxes to indicate specific equipment inspected/serviced: Tank 1D. ®1 - R49u Tank ID: 02 -Plus p In - Tank Gauging Probe. Model:yR 847398-199 ❑ In - Tank Gauging Probe. Model: VR 847390.109 Annular Space or Vault Sensor. Mndph VR 794380.301 VR 794UD-352 Annular Space or Vault Sensor. Model: VR 7943RD -sol Piping Sump \ Tt+ench Sensor (s). Model: VR 794389-352 _ Piping Sump \ Trench Sensor (s). Model: Model, �F3® tib er Fill Sump Smsor (s). Model D Fill Sump Sensor (s). p Mechanical Lint T pak Detector. Model: None ... Mechanical Line Leak Detector, Model; Novo Electronic Uric Leak Detector. Model: vR seriea x484 Elocumie Line Leak Dctector. Model: vR serios eine Nene ❑ Tank Overfill \ High -Level Sensor. Model: Nona ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ Tank Overfill \ High-Uwl Sensor, Model: Cl Other ( specify equipment type and model in Section E on Page 2). Tank ID: 03 - Prem Tank )1D• 04 - Diesel Q I» -Tank Gauging Probe. Model:VR 847390.198 ly In -Tank Gauging Probe. Model: VR e47s3o-s� X. Annular Space or vault sensor. Model:yit 9eaa9aoe9 Sensor Model: VR 794380-352 Annular Space or Vault Sensor- 1Vindel V 794384.301 Piping Sump 1 Trench Sensor (s). Model vR 78438o�s5k jr Piping Sump \Trench (s). _ Fill Sump Sensor (s). Model: 5�3®�� Fill Sump Sensor (s), Model: „ O' U Mechanical Lina Leak DGtputa. Mod6L Nona p Mechanical Linn r rile T)eteemr. Model: Nona Electronic Line Leak Detector. Model: VR Series 8484 Electronic Line Leak Detector. Model; VRSerles 8434 p Tank Overfill 1 High -Level Sensor, Model: Nona Ll Othcr (opeoify equipment type and model in Srct;nn F. nn Page 2). ❑ Tank Overfill 1 High -Level Sensor. Model:.. -None ❑ Other (specify equipment type and model in Section F on Page 2). Dispenser ID- 01-02Dispenser EX 03-04 f� Dispenser Containment Sensor (s). Model: O, 0 Dispenser Containment Sensor (s). Madel: ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Shear valve (s). ❑ Dispenser Containment bloat (s) and Chain (s) - Dispenser ID• os -os Dispenser Containment Sensor (s). Model: O - panser ID. 07.08 ispenser Containment Sensor (s). Model: l ❑ Shear Valve (s). p gi*pencer Containment Float (s) and Chsin (a). hear Valve (s). Dispenser Containment Float (s) and Chain (s). 1.1 fig er D og-�0 penser • 11-12 Wrnscr Containment Sensor (A). Model: Pap Dtspensee Containment Sensor (s). Model hearValve (s).hear ispenser Containment Float Wand Chain (s). Valve (s). Dispenser Containment Float (s) and Chain (s). *If the tbcility conrainc MOW. tanks nr dispensers. copy this form. Include information 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 manufeeturer°s guidelines. Attached to this Certification is Information (e.g. manufactures' checklists) necessary to verify that this information Is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, [ have also attached a copy of the; ( check all that apply): A SystemAct-UP ® Alarm history report Technician Name (print), SSS-ChrlsM Siglature:—a=; Ccrti4"ication No.: 566-95-8259 License. No.: 485184 Testing Company Name: Ser. Sta. Sys. __ Phone No.: 40$ 971-2445 Site Address: 3725 N Tracy Blvd. fl 1-205 Date of Testing0gervicing: 3/31104