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04`/26/2004 14:23 4089710 SSS INC p PAGE 03 <br />Monitoring System t Certifleation <br />For' (ler £31, All Juri.t'dictiiurs 147ithitil The State. of C:C7ffiornia <br />A whoritw Cited: Chaplcrf� 6.7, Necrlth and Safety Corte; Chapter 16, Division 3, Title 23, California Code of Rr,gulutions <br />-Phis honor inust be used to docamen.t testing and servicing of morritorin- equipment. A separate certification or repoil .must be <br />1r • 14rcd :For each monitorings stem con rrol panel. by the technician who perforins t11e work. A copy of this fonn must be provided <br />to the tank systcnn owner/oporator. The owner/operator must submit a copy of this fonn to the local agency regulating 'UST system <br />within 30 days of test date. <br />A. General Information <br />T acility Ntjnlc: Tracy Blvd Shell & Mini Mnrf <br />Bldg. No_: <br />Site Address; 3725 N. Tracy Blvd. 1-205 City: Tracy, GA _ zip; 95376 <br />Facility Contact Terson: Andy _ Coiutact Phone No.: 209 835-7608 <br />Make.'Modcl of Monitoring System: V1R Simplicity Date of Testing/Servicing: 3131104 <br />li, filiventory of EquipliTIevit Tested/Certified <br />Cheek the appropriate boxes to intlicate specilic equipment inspected/serviced: <br />1.anl: r1)• o1.Regu <br />❑ In - T;lnl< (ouging Probe. <br />Mc,)ilCl: <br />VR 847390.109 <br />N Annulai space or Vault Sensor. <br />MoCIC1: <br />VR 794360.301 <br />(g Pilliq l SUn1p \ french Sensor (s). <br />Model; <br />VR 794380-35Z <br />Ig Dill Sump'SurisCa'(s). <br />Model: <br />VR 794380.2118 <br />(� \4ccllaitieal I.Ane Leak Detector. <br />Model <br />None <br />1=..luclronic Line Leak Detector, <br />NJOdCl: <br />VR Series 8484 <br />❑ 'lank Overfill \ 1-1igh-Level SCIISDr. <br />Model; <br />None <br />❑ Other ( spccil'y ecluipnlcnt type said model in Section E on Pagc 2). <br />'t'sut 1:.I l). 03 -Pri=m <br />❑ ht I"Onk Gauging Prirl>C. <br />MoilC11 <br />VR 847390.109 <br />0 AV1rlllla[ til)iKv of Vut,lr S011501', <br />Modell <br />VR 704190-901 <br />DO Piping Sunil?', TI'CnCh Scnsor (S), <br />Model: <br />VR 794380.352 <br />® l ill SUn111 Sensor (S). <br />Model: <br />VR 794380.208 <br />❑ Mcehanieol Lina Luak Detector. <br />Model: <br />None <br />® EICCtronic line Leak Detector. <br />Model: <br />VR Series 8484 <br />❑ Tank Ovm'fill "1 Higll-Level Sensor, <br />Mot1e1: <br />Nona <br />0 Culler (. sped IV r�rlllir,tvynl type and model in Section 1: on Page 2), <br />1>ipettser 11) 01-02 <br />® i)ispuurrCnlluriltnteniSensur(s). Model: Seaudreu500C <br />❑ tiluur Valve (�). <br />3 Dispenscr C"anlainntent 1=1oat (s) and Chain (s). <br />1yi.c1la:nser lU• 0�-nF <br />I )i<I>unser ('onlailir11011t S(;IlsfF4ililCl: ecauureu 5o0C <br />❑ Shear Vuk'o (s'), mm <br />❑ l.',lispMilair f_'pnCpimm�nt pin:1t (c) chid 013in (5). <br />Disperiser ID.• 09'1Q - <br />1)ixpenser C'utllainnlcnt Sensor (s), Model: Beaudreu 500C <br />❑ tiltcar Vows I.s1. <br />la <br />Dispenser C'ontilinment Flout (s) wid Chain (5). <br />,rank IDL -0 -2 -fl -u-5---- <br />Q to - Tack Gauping Pratte. <br />:] <br />Mod(:l, <br />VR x47390.109 <br />jg Annular Space or Vault S@11SUI', <br />Model: _ <br />VR 794380.301 <br />jg Piping Sump \ Tronch Sensor 00, <br />Mo4cI: <br />vee 1114alsu-s S2 <br />3 Fill Surnil Sensor (s). <br />Model: <br />VR 794LBO--20a <br />❑ Mechanical Linc Leak Detector. <br />Model: <br />None <br />Llectronic Linc Leak Detector. <br />Model; <br />VR.1-1* 0404 <br />❑ 'Tank Overfill � Higl,-Level Sensor, <br />Model: <br />None <br />Q Other ( specify equipment type and model in Section E on Page 2). <br />Tank TD• 04 -Diesel <br />0 In - "tank &Ugillg PrObe. <br />Modcl: <br />VR 847390.105 <br />Annuisr Spsire. Ar ljault Sen.cnr. <br />Modell <br />UR 794380.301 <br />Piping Strmp,• Trench ScnSOr (s), <br />Modcl: <br />VR 994380.382 <br />jg EillSumpSOn50I'(S). <br />ModCl: <br />VR 794380,208 <br />M Mechanical Linc Leak Detector. <br />Model! <br />None <br />29 1-11ccironic Line Leak Detector. <br />Model: <br />, VR Serres 8484 <br />❑ 'funk Overfill \ High -Level Sensor. Model: None <br />❑ Otllcr ( specify equipment type and model in Section k. on huge 2 <br />Dispenser .ill, 03-04 <br />99 Dispenser Coelain111cnt Scnsor (s). Model!, <br />U Shear Valve ('5). <br />❑ Dispcnscr Containment Float (s) and Chair (s), <br />amiudeou 5000 <br />1Dispcnser I D. 07.08 <br />Dispctlscr C'ontainrtletli Sensor (S). Model; Be, udreu 500r <br />❑ $hear Val~,�e (s). <br />Q Dispenser Containment Float (s) and Chain W. <br />Dispenser Ill" 19.12 <br />N Dispcnscr C'ontainmcnt Scnsor (s). Model: B-udreu 500C <br />❑ ;Itcal,VOIVC (s). <br />❑ Dispcnscr Containment Flnat (s) and Chairl (s), <br />"Ill' the `I:lcilily contains niche tanks or dispensers, COpy (his It)r111. Include inlorn-wtion I'or every tank and dispefner at the facility <br />C. Certification - I cel'tify that the UILlip111011t identified ill this document was iospect0/serviced ill accordance with the <br />m:emrl'ariurer's g1►idelincs. Attachell to this Curiilicadon is information (e.g. manufactures' checklists ) neeesSnev to verifv that this <br />infoeoiation is correct aild a Plot P18n showing the layout Of 111011itOeLng equiplliel)t. Fal- ally CgilAj)ItleB)t Capahlc of l;enta'ati0g such <br />r•Cp()r•ts, I have also attached a copy of tile', ( check cal/ iha! apply): ❑ System met -up ❑ A13rm history report <br />Technician Name (print): SSS-ChrisM Si -nature: <br />No ' 4:f, i: L (.:iccnse. No.: 485184 <br />11.11 U.:1ur .. n <br />1 esting C;olnpatly Name: Ser. Sta. S s. Phone No., 408 971-2445 <br />Site Addruas: 3725 N. Tracy Blvd- a 1-205 Date of Testing/Servicin5,,: 3131104 <br />