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09102/2003 10:36 4069710135 SSS im PACE 02 Moniftorinfosystem Equipment C%tification For:Use By All Jurisdictions Within The Stwe of California Authority Cited:Chapter 67.Health and SOATY Code'-Chapter 16,Division 3° Title 23, California Code of Regulatiom This form must be to doctinxtit testing and servicing of monitoring equipmetlL A s to fi elan ar re t bu preeared for each monitoring sytitem control V=1 by the technician who Performs the work.A copy of this form must be provided W aW Ldnk systen►a /Cllg.UserNan , The owner/Cfg.UserName must submit a copy of t1lis form to the local agency regulating UST st withm 30 days of test dare. A. General Inf c -o Facility Name: Ripon Shell Bldg. Nn.: Site Address; E.Main St.a Hwy.99 City: Ripon, CA Zip: 95366 Facility Contact Perron: David Ctr AACL Ph=C No.: (2 09)5 e1 ofonitaritl0 Sys i ici Date of Testing/Servicing: 03127102 B. Inventory of Equipmentt ertifi Cheek the appropriate bozo to indicate specific MilpavenatIn ct ed: Ta t -negu Tank ;02PlItin - In-Tank Gauging Probe, Model: VR -tea in In-Tank Gauging Probe. Model:_s 847stio,lev IS Annular Space or vault Sensor. Model: VR Annular Space or Vault Sensor. Model: VR 7943M.302 il Piping$ump 4 Trcaxh Scnsua(n). MuJ►i: YR r Ptphtg Su \t rench Sensor(s). Model: VR Tusso4es 13 Fill Sump Senior(s). Madel e ❑ Fill Sunt Saror(a). Model: ❑ Mechanical tine Lcak Detector, Model: None ❑ Mechanical Lime(gak Detector, 1: None glectronie Line Lank Datcwtqr. Madel: VRO-l" 6"Aswily Unv]c ak Dommor. Model; vm manes as ❑ Tanlk Overfill\Nigh-1-ml Sensor, Model: ❑ Tank Overfill\High4cvel Sensor. Model: Nona 13 Other(Specify e4uipmcat We mid model in Section E on Page 2}. 13 Other(spccify ip t type and model in Section 6 on Page 2). Tank Tank �® ❑ in-Tank Gsug' Model: ❑ In-Tank Gauging Probe. Morcel: ❑ Annular Space or vault Sensor. l: ❑ Annular Space or Vault Sensor. Mmol: ❑ Piping Su \Trench Sensor(sj Model: ❑ Piping Su \Trench Sensor(s). Model: ❑ Fill SuTnp Sensor(s). model: ❑ fill Sump Sensor(s). Model: El Mechanical Line Leek Octector. Model: 0 Mechanical Unc Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 0 Voctranic Line Leak Detector. Model: Tank Overfill\ i-.h-Levet Sensor, Modeh ❑ Tank Overfill\High-Level Seraor. Model: ® 0 ther(apecit'y equipment type and rratdei in Section,E on Page 2), Other(specify equiprnent type said model in Section E on Page 2), ispe ) • 0142 Dispenser . 03-04 ll Ut sa•Containtn Sensor(s) Model: t E Dispenser Contain t Sensor(s), Model: ua r e t ❑ shearvalve(F). ❑ Shoar vah-,(s} Dispenser Cordainrnent Float(s)and Chain(s). ❑ Dispenser Contain ,Float(s)and Chain(s). is user ID, 5Dispenser 07-08 C"Penser Containment Sensor(s). Model: yR t N Di-venser Containment Sensor(3). Motel: VR 7 ❑ Shear Valve(s). ❑ Sheer Valve(s). EOD,spmser Containment Float(s)and Chain(s). 13 SD1ti tLto'YplvCr= (w) in t Float(s)and Chain(s) . Di r t Dispenser Containment (s). l: ❑ Db Containment r(s). Model:Valve(0. ❑ set Containment Float(,)and Chain(q ❑ Dispenser Coolainrnent Float(s)and Chain(s). •)frite facility contain more tanks or dispensers.copy this form.tnc information'an for every lank and dispenscr at the facility C.Ce Icatlon- i tfy that the apipatent ideattilied in this docouseat was ilispecicdfaerviced in accordance with the manufacturer'sguiddium Attached to thin Cenilleadti on is infer (e.g.manufactures' ° s)neeesstry to verify,that thin it t0formation is correct and a Plot Plan showing the layout of monitoring ottialpmeat. For any ip tal Rt capae of generating,such rep s.l have also attached a copy of the; (check affAW ): [3 System set-up 0 Alarm history report Technician N rint): tile$ Si _Original on file at SSS C tion o.: 552-61-61T6 License. o,: 495184 Testing Company Name: Sor. ta.Sys. Phone No.: (428)971-2445 Site Address: 341 E.Main t.@ Hwy.99m_ Date of Tes ° /Servic 27102