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Monitorh#System Equipment4oertification For Use By All Jurisdictions Within The State of California 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 monitoring system control panel 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 system within 30 days of test date. A. General Information Facility Name: Yosemite Shell Site Address: 1330 E. Yosemite @ Highway 99 Facility Contact Person: City: Manteca, CA Bldg. No.: Zip: 95336 - Contact Phone No.: (209) 825-0332 Make/Model of Monitoring System: ? -F\,, S _ 3 r J / 1I Date of Testing/Servicing;Sf84_� B. Inventory of Equipment Tested/Certified '7 P z Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ED: 01 -Rego Tank 02 -Prem ID: 0 In - Tank Gauging Probe. Model: VR 847390-10e 0 In - Tank Gauging Probe. Model: yR 847390-109 /Annular Space or Vault Sensor. Model: VR 794390-409 2,1 Annular Space or Vault Sensor. Model: —VR 794390.409 Piping Sump \ Trench Sensor (s). Model: VR 794380-352"0' Piping S ump \Trench Sensor (s). Model: VR 794380.368• � 'Z Fill Sump Sensor (s). Model: VR 794380462- -ZOO Fill Sump Sensor (s). Model: VR 794380362- zas Mechanical Line Leak Detector. Model: vaporiess LD2000 0 Mechanical Line Leak Detector. Model: vaporiess LD2000 0 Electronic Line Leak Detector. Model: None 0 Electronic Line Leak Detector. Model: None 0 Tank Overfill \ High -Level Sensor. Model: None 0 Tank Overfill \ High -Level Sensor. Model: None Other ( specify equipment type and model in Section E on Page 2). 0 Other ( specify equipment type and model in Section E on Page 2). Tank ID: 03 -Diesel Tank ED: 0 In - Tank Gauging Probe. Model: VR 847390-109 0 In - Tank Gauging Probe. Model: ? Annular Space or Vault Sensor. Model: VR 794390-409 0 Annular Space or Vault Sensor. Model: ? Piping Sump \ Trench Sensor (s). Model: VR 794380352 0 Piping Sump \ Trench Sensor (s). Model: ? o Fill Sump Sensor (s). Model:VR 7943804=Z 0 Fill Sump Sensor (s). Model: ? rY Mechanical Line Leak Detector. i� Model: vaporiess LD2000 0 Mechanical Line Leak Detector. Model: ? Electronic Line Leak Detector. Model: None 0 Electronic Line Leak Detector. Model: ? 0 Tank Overfill \ High -Level Sensor. Model: None 0 Tank Overfill \ High -Level Sensor. Model: ? 0 Other( specify equipment type and model in Section Eon Page 2). 0 Other ( specify equipment type and model in Section E on Page 2). Dispenser ID: 01-02 p Dispenser ID.. 03-04 ispenser Containment Sensor (s). Model: VR 794380322 spenser Containment Sensor (s). Model: VR 794380322 0 Shear Valve (s). 0 Shear Valve (s). 0 Dispenser Containment Float (s) and Chain (s). Dispenser Containment Float (s) and Chain (s). Dispenser E. 05-06 Dispenser ID• 07-0$ Dispenser Containment Sensor (s). Model: VR 784380322 Dispenser Containment Sensor (s). Model: VR 794380322 0 Shear Valve (s). 0 Shear Valve (s). 0 Dispenser Containment Float (s) and Chain (s). 0 Dispenser Containment Float (s) and Chain (s). Dispenser ID: 09-10 p Dispenser ID: 11-12 /Dispenser Containment Sensor (s). Model: VR 794380-322 n�,Dispenser Containment Sensor (s). Model: VR 794380322 0 Shear Valve (s). 0 Shear Valve (s). 0 Dispenser Containment Float (s) and Chain (s). 0 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 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): eff System set-up � Alarm history report Technician Name (print):SSS-JoshH Signature: Certification No.: c'�56. License. N4 4 Testing Company Name: Ser. Sta. Sys. Phone No.: (408) 971-2445 Site Address: 1330 E. Yosemite @ Highway 99 Date of Testing/Servicing: 71SX4 -7f