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JUN-25-2005 07:26 S Vice Station Systems 408 938 8888 P.03 <br /> �+u�z a•� JJ'—te.i vv vv...r.�r• ��®vw.n..• ...... <br /> • f r Systemti <br /> ,For YJse By All Ari, tions WAIn"W&M of Cal fade <br /> Awhwo Cited. CkAprer 6 T,Health=d So&Code;Chapter 16,Divistnn 3. Tide 23,Calff mia Cade 7fWi0m <br /> Thk&=znuet in OW to of m=Mrmg oqmF==t. & MV&Mon or tntlstNORM i� <br /> . by ft fthnitim wto Peftms the watt A copy of this form nuist be provided <br /> to the twk owner/operator. The o /operator must submit a wpy of this form to dm lo*d agmicy ropUft U'S'T sysimn <br /> widiin 30&P oftgt date. <br /> A. GonwalInformation <br /> FadHty Name.Tracy Blvd Shell&Mini Mort Bldg.No.: <br /> Site N.Tracy Blvd.0 1-205 City. Tracy, CA zap: OWO <br /> Famlity t ' .: (209) <br /> MaWModal of MWUwft Systern: WAR SitrtPHOR t Daae ofTesdnWSOM 49: MW05 <br /> B. invoufty of Equipwrat Tcetx*CerMed <br /> TMk IDe <br /> Tnk IN <br /> a in-Tj"jFGjjjR� 0 in, g - Model: 7 <br /> ® AWMW IPPM or Paul[SOM mood., ? Cl Amla Spazo or Vault : 7 <br /> Q -FM Sw* t (O % ModelMow` 7.... 0 pill Swmp o (c), (s� a <br /> z <br /> QMcchaniw L40 Leak Datcow. Model: 9 p Mnh=&W Lim Look - Mod& 7 <br /> p nk Lina teak 7 qMOMWO IAC teak OMMr. mom: <br /> p TnkOvwfili1 i -[.eves Somor. Modeb 9 p Took Ovabt!kKwh-.evdSensor • 4 <br /> 0 (vagwy eq V+ in F oa 2} p C (sP Y "M and inOijaij <br /> Tank ID: T <br /> 0 ( 1a-Tank Gaugng Probe 7 <br /> p Sys a$Vault Seirwor. Model: 9 ® Sp oT4 b t 7 <br /> p e9't iidz`seaw(4 Mood., 4 <br /> 13 (9). MW, 9 C) 1411 SMP 3ca W(s). <br /> ® M Un took r. : ' Q b4counieal i inc L");ik7"Wl : q <br /> 0 .• l.$w Ld*040mr. Modci: Z p lacmuic Lim UA OMaW. Mom, _...__.-.-- <br /> O QVOR 11HiSTt-L,sw,cl sow. Mode:I C! TA*OVUM! E"Sear. : 7 <br /> 0 ( qp aW model in oil p ). p Other(VOW OQWPNAV type and modd in Section a onhP2). <br /> 13-14 <br /> Ca cor : ncnau s. <br /> Slim Vd"(51 Valve(s). <br /> G (s)pad Gain Ge}. ® E•'° (f)azul C�zxat(s?. <br /> ® _• -... - - <br /> [] am Value(0 p SLco►valve(s). <br /> Q (s) (q) p Di C*o%I t nm(s)an 6 C Wim(s). <br /> ♦ . • �e <br /> D <br /> CAniil Sc r(s R ® VatvC(s). Cz15°r s. 9 <br /> OQ Eiiipar Vah►c ON <br /> (�• ohm <br /> +atlas ib'iiftiiMowe tarls or ' Ow9dafimumbulal [l tiir Qw1�11GARk agsE at tbz:iaaiiigt <br /> C.COTHj"dpd_ t pe ft twat elan in Oft WAS rid itt -i*UNI <br /> p cp d&CerOftAftu is (041 um ) to M*OM tMw <br /> bdumtka is Conta sad a no pin ShOYANS do lww of quipment. For any rrqul mpabk of <br /> geftwMINg <br /> 1 have dao gmwW a ow or dM4 ( alt t it A 0 Iiia[ r <br /> Tedmicion xaMMO andyw $i <br /> L : 485164 <br /> Too*Compay Nam. $94*wa 11 e UO No: <br /> Oft : SM X T -6 M5 Date of'Icstb t f/'a vi g. <br />