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t. APR -04-2006 09:15 Service Station Systems 4oe 939 eeee P.02 Monitor*system Equipmenttertinicati-on e+ For Use By All Jurisdictions Within The State of Calffornia 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 prepared for each tDaonitoring system control panel by the technician who perforans 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 to the local agency regulating UST system within 30 days of test date. A. General Information Facility Name: Tracy Blvd Shell & Mini Mart Bldg. No.: Site Address: 3725 N. Traq Blvd. a 1.205 City: Trac , CA zip:_ 95376 Facility Contact person: MaCk Contact Phone No.: (205) 835-7608 Make/Model of Monitoring System:_/ --_Simplicity Date of Testing/Servicing: 3121/06 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID• 01-Regu Tank ID° 02 -Plus 0 In - Tank Gauging Probe. Model: VR 347390-109 p In - Tank Gauging Probe. Model: VR 841390-109 Ig Annular Space or Vault Sensor, Model: VR 784380.301 5 Annular Space or Vault Sensor. Model: VR 794330.307 IM Piping Sump \ Trench Sensor (s), Model: V11794380 -M2- Piping Sump \ Tronch Sensor (s), Modck VR 794889.392 11 Fill Sump Sensor (s). Model VR 794310-201 ). Fill Sump%IL�ink Model: VR 794330-203 13 Mechanical Line Leak Detector. Model; None ❑ Mechanicaak Detector. Model: None IN Electronic Line Leak Detector, Model: VR Series 0444 11 Electronic Detector. Model: VR cedes 84M 0 'rank Overfill \ High -Level Sensor. Model: tons __-____...- .. 0 Tank Overfill 1 High-L.evcl Sensor, .Model: None 0 Other ( specify equipment type and model in Section E on Page 2). 0 Other ( specify cquipmont type and model in Section E on Page 2). Tank ft -9. -Prem Tank Ili• 04-Die8dl ❑ In - Tank Gauging Probe. Model: VR84739D-109 ❑ In - Tank Gauging Probe, Model, VR 847890-109 Annular Space or Vault Sensor. Model: VR 794330.301 QQ Annular Space or Vault Sensor, Model: VR 7"S"1 ® Piping Sump \ Trench Sensor (s). Model; VR 7MUD-392 lig Piping Sump \ Trench Sensor (s). Model: VR 784930-862 Fill Sump Sensor (s), Model• VR 79080.208 Q_Q Pill Sump Sensor (s). Model: VR 794310-208 0 Mechanical Line Leak Detector, Model: None (3 Mechanical Line Leak Detector. Model: None IM Electronic Line Leak Detector. Model: VR series 34M S Electronic Linc Lcak Detector, Model; VR Segos 8484 0 Tank Overfill \ High -Level Sensor. Model: N000 0 Tank Overfill \ High -Level Sensor. Model: None ® Other ( specify equipment type and model in Section E on Page 2). p Other ( specify equipment type and model in Section E an Page 2). 1)14 eraser m- 01.02 Dispenser 03-04 M Dispenser Containment Sensor (s). Model: 6esuareau 400 jj Dispenser Containment Scnsor (s). Model: Beaueneau 403 19 Shear Valve (s). IM Shear Valve (s). [I Dispenser Containment Float (s) and Chain (s). ® Dispenser Containment Float (s) and Chain (s). Dispenser ID, 0"6 Dispenser - 07.08 nil Dispenser Containment Sensor (s), Model; Reaudreau 403 Qg Dispenscr Containment Senior (s), Model: Beaudreau 400 11 Shear valve (s). 12 Shear Valve (s), ❑ Dispenser Containment Float (s) and Chain (s), ❑ Dispenser Containment Float (s) and Chain (s), Dispenser ID• 09-10 Dis enser : 11-12 P --_.--.---.___-- N Dispenser Containment Sensor s) . ( Model: v seaareau a/1 S Dispenser Containment Sensor (s). Model: I3eaudreau 409 Shear Valve (s). jg Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s), 13 Dispenser 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 eertify that the equipment identified in this document was Inspected/serviced 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 and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attacked a copy of thc; (check &U that apply): ❑ System set-up 0 Alarm history report Technician Name (print): Steve Parmenter Signature: _ _ _- Mfg, Cort.#.: 006-05-1621 ICC# 52612 T License, No.: 485184 Testing Company Name. Ser. Sta. SME, Phone No.:� (408) -2445 Address: 3725 N. Trac Blvd. a 1.205 Date of Testing/Servicing: 3121106