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, IN/1011itoriull PSoystern Equipment 3,rtification f-'o/ 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: Waterloo Shell Bldg.No.: Site Address: 4315 Waterloo Rd. @ Hwy. 99 City: Stockton, CA Zip: 95205 Facility Contact Person: William Contact Phone No.: (209) 931-3674 Make/Model of Monitoring System: V/R Simplicity Date of Testing/Servicing: 5/26/04 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:01-Regu Tank ID: 02-Prem ❑ In-Tank Gauging Probe. Model: VR 847390-109 ❑ In-Tank Gauging Probe. Model: VR 847390.109 2g Annular Space or Vault Sensor. Model: VR 794380-302 Qg Annular Space or Vault Sensor. Model: VR 794380-302 N Piping Sump\'french Sensor(s). Model: VR 794390.205 Qg Piping Sump\Trench Sensor(s). Model: VR 794390.205 ❑ Fill Sump Sensor(s). Model: None ❑ Fill Sump Sensor(s). Model: None ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None Qg Electronic Line Leak Detector. Model: VR series 8484 Qg Electronic Line Leak Detector. Model: VR series 8484 ❑ 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 E 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: 7 ❑ 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\High-Level Sensor. Model: ? ❑ Tank Overfill\High-Level Sensor. Model: ? ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID- 01-02 Dispenser ID• 03-04 Z Dispenser Containment Sensor(s). Model: VR 794380.322 Qg Dispenser Containment Sensor(s). Model: VR 794380.322 Qg Shear Valve(s). 99 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 2g Dispenser Containment Sensor(s). Model: VR 794380.322 Qg Dispenser Containment Sensor(s). Model: VR 794380-322 Qg Shear Vake(s). Qg 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 Vale(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ 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): ❑ System set-up ❑ Alarm history report Technician Name(print): SSS-RonW Signature: Certification No.: 006-05-0826 License.No.: 485184 Testing Company Name: Ser. Sta. Sys. Phone No.: (408) 971-2445 Site Address: 4315 Waterloo Rd. @ Hwy. 99 Date of Testing/Servicing: 5/26/04