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0026/2004 14:23 4089710 'S SSS INC PAGE 04 Monitor-IMonitor-Ing SystemEquipment eticaio For Use Ry X111 lur-isdictions• Within 'rhe State of CalVbr nia Awhor-in, Cited; Chapter 6.7, Health acrd Srlfety Code; Chapter 16, Division 3, Title 23, Califor-nkr Cod( of Regulations This 1'(lr111 most be used to document testing and servicing of monitoring equipment. A separate certifict must be prepared fqr each monitoring system control panel by the technician who performs the work. A copy of this form must be provided in t:hc melt: system owner/operator. The owner/operator- utast Submit a copy of this form to the local agency regulating UST system within 30 days of test date - A. General Information Fucility Nanw; Tr2CY Blvd Shell & Mini Mart Bldg, No.;. Site Address: 3725 N. Tracy Blvd. _ 1-205 _ City: Tracy, CA Zip: 95376 l:alciiity contact Person: Andy T mm — Cantu(;tpltuuc YJu.; 200) 835-7608 Malcc;Moclel of Monitoring System: V1R Simplicity Dote of Testing/Servicing; 3131104 B. itiventory of .Equipiiie11t Tested/Certified Check tits fippropriatc (taxes to indicate specific cquipment inspoetedlseevieed: Tank ID• ❑ In -'rank UauginE Prohc. Mnd'd —I— ? n A11ntl1;li' S11lce ol. Vaalt Sensor. Model: ? ❑ i'tping SUnlp \Trencll SUM- (S). \,Iodel: ? ❑ Fill 1.tulll) Sensor (s), Model: 7 n h'IcehlniCal I.ine 1._euk Detector. Model: ? ❑ Electronic I...ine Lcal< Dctccttlr. Model: 7 ❑ 'I:uik Ovo lilt \ 1•ligh-Level Scnsor. Modcl: ? ❑ Oflier e, specify equipment type Lind model ill Section I; on Page 2). Tank LD' ❑ in -'rank Gouging Prpbc. Model: ? [j A m dur iltucc to V41.11t Sensor. Model: ? D Pipitlg Sump \ •french SCIiNor (s). Model: 7 ❑ Fill Sump Sensor (s). model: ? p �1ce6:u,iceal 1-inc Iauk Duteotoa•, NA(Idul: I - ❑ f3loclrunic 1-ine Leak DctWnr. Model: ? [] Turk Ovcrl'ill' I lith-L.cvcl Sensor. Model: ? ❑ (l,hr ( �l,r,�ifv arluipnlcnt type and model in &ction r oil Paivc z). Dispenser i1)• 13-14 ® Di's11enser ('ollulinn'lunt Sensor (s). Model; Beaud;&d 5000 ❑ Shear Valve W. ❑ l)lapialst:r Containment float (s) and Chain (s), Dishcnaci iT) .. I)iSimiscrC'oilklinnlcllt Setlsor (s), Mudul: ? ❑ Shear Valve (5). ❑ 1iiS i)Cn5C:1' ('Olitaillnlenl 17loat tsl and ('hail (s). Tank IDL Q In - Tank C iauging Probe. Model: ? >;) Annular Space nr Vau11 Sensor. Model ? ❑ Pipill� SSamp 1 I TCnCn Model: ? 0 ('ill SLinnp Scrl (S), Model: ? ❑ Mechanical Line Leak Detector. Mo(tcl: 7 U Elecn'onlc Une teak Dctt:clul. Madel; 0 Tank Overfill \ i-ligh-Leve) Sensor, Model: 7 Q 0111et' ( spcclfy Cquipnlent type and model in SeCtioll E on Page 2). Tank ID• ® In - Tank Gauging Probe. Model: ? ❑ Annular Cpnrn tw Vault Sensor. Model:— fl Piping Surrlp \ Trench Sensor (s). Modcl: ? ❑ fill Sunlp Sensor (s), Model; 7 Ln Mecilanicul Linc 1_.cak Detector, Modcl: ? ❑ Electronic Line Leak Detector- Model: ? ❑ 'Tank Overfill \ High -Level Sensor. Modcl: ? _ ❑ otllcr ( specify equipment: tyl?c and mudel in Section F on Pag"c 2), Dispenser UD: 15-16 X Dispenser C:ontainnlent Sensor (s). Mixlel: 6eaudrou 5000 ❑ Shear Vulvu (s). Q Dispenser Containment hloal (s) and Cbain (s). >7ic[tP.vt.cer TD: .. i)i5ponscr CoittalmllCnt Sensor' {S). Model: ? ❑ Sllcat' Valve. (s). p Dispenser Containnlcnt Float (s) and Cllain (s). Dispenser ID, Dispenser ID- D 1)i'�lit: nacr ('ollIaill nlcnt Sensor (s). Model; ? [j Dispenser Containment Sensor (s). Model: 7 U Soar Valve (S'), ❑ Shcar V;Jlve (�). fl I>ispcusi r C°ontainmcnt bloat (s) and Chain (s). ❑ Dispenser Containnlcnt Float (s) and Chain (s), ll'thc facility eoniains more tanks Or dispcnscls• copy this form, l,lcludc information for every tank gild dispcnscr at the facility c;. ('ertlliLiitl®n - I certify than (lie equipment identified in this ilocurttcitt was inspected/serviced in accordance with the nianuractnrt•rN t;uidelincS. Albrtlled fo this C;crtilieatlan is intiennatiun (e,g. ilia flu factures° clieckli5ts ) necessary to verlfy that this inrnr illation is cor'r'ect and a Ilial ['14111 Shotvillg the layout Of monitoring, equiprttent. Far any i.•yuiprncnt capable oil geilcrating 51101 replirtS. I ]lave also atlitthed a Copy of ehct (Clieck all that applW; 0 System lief -up ® Alarm history report Technician Name (print): SSS-ChrisM Signature: C'enihcation No-: License. No.: 485184 Testing C001pa.rly Namc: Ser. Sta. Sys. _ Phone No.: 408 971-2445 Site Adclrc.ss: 3725 N. Trany Blvd- (RI -205 -„ _ Date of Testing/Servicing: 3131104