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MonitorinfSystem Equipment 9ertification For Use By All Jurisdictions Within The Stuie of Calijurnia Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of'Regulatiom This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring,system control pane by the technician who performs 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 systems within 30 days of test date. A. General Information Facility Name: Shell 135816 Site Address: 341 E. Main St. @ Hwy. 99 Citv Ripon, CA /T 95366 Facility Contact Person: David Contact Phone No.: (209) 599-4454 Make/Model of Monitoring System: V/R Simplicity Date of Testing/Servicing: 03/27/02 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:01 -Regular Tank ID 02-Premium N In-Tank Gauging Probe. Model: VR 847390.109 In-'Tank Gauging Probe. Model VR 847390.109 N Annular Space or Vault Sensor. Model: VR 794380.302 Annular Space or Vault Sensor. Model: VR 794380-302 5 Piping Sump v Trench Sensor(s). Model: VR 794380.208 99 Piping Sump\Trench Sensor(s) Model: VR 794380.208 ❑ Fill Sump Sensor(s). Model: none ❑ Fill Sump Sensor(s). Model: None ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector Model: None 99 Electronic Line Leak Detector. Model: VR 331196.001 Qg Electronic Line Leak Detector. Model. VR 331196-001 ❑ Tank Overfill\High-Level Sensor. Model: None ❑ Tank Overfill\High-Level Sensor, Model: None ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section F on Page 2) Tank ID• Tank ID• ❑ In-Tank Gauging Probe. Model: ? ❑ In-Tank Gauging Probe. Model: ? ❑ Annular Space or Vault Sensor. Model: ? ❑ Annular Space or Vault Sensor. Model: ? ❑ Piping Sump\Trench Sensor(s). Model: ? ❑ Piping Sump\Trench Sensor(s). Model: ? ❑ Fill Sump Sensor(s). Model: ? ❑ Fill Sump Sensor(s). Model: ? ❑ Mechanical Line Leak Detector. Model: ? ❑ Mechanical Line Leak Detector Model ? _ ❑ Electronic Line Leak Detector. Model: ? ❑ Electronic Line Leak Detector. Model: ? ❑ Tank Overfill A High-Level Sensor. Model: ? ❑ Tank Overfill\High-Level Sensor Model ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other 1 speeity equipment type and model in Section l an I a Lc 'I Dispenser ID- 01-02 Dispenser ID- 03-04 ® Dispenser Containment Sensor(s). Model: VR 794380.321 N Dispenser Containment Sensor(s). Model: VR 794380.321 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID- 05-06 Dispenser ID- 07-08 99 Dispenser Containment Sensor(s). Model: VR 794380.321 2g Dispenser Containment Sensor(s). Model: VR 794380.321 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID• Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *I(the laeility contains more tanks or dispensers,copy this loi in. include inlormatwn tur e�cry tan/.and di6ponsel at the lacaluy C. Certification - I certify 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 attached a copy of the; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name(print):SSS-Josh Signature: Original on file at SSS Certification No.: 552-61-6176 License. No.: 485184 Testing Company Name: Ser. Sta. Sys. Phone \u (408) 971-2445 Site Address: 341 E. Main St. @ Hwy. 99 Date of"festinu Sery icinur 03/27/02