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06/19/2003 16:35 40897101?5 SSS INC PAGE 02 Monitoring System Equipment ertifieation Fol-Use By All Jurisdictions Withh?. The State of California Aulhat ity 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_sMarate certification or reRort must be prepared for each rnonitoting system control panciby the technician who performs the work.A copy of this farm must be provided to the tank system owner/Cfg.UserName. The owner/Ufg.UserName inust submit a copy of this form to the local agency regulating UST s within 30 days of test date. A. General Information Fac:iiily Name: Shell 136143 Bldg,No.: Site Address: 4315 Waterloo Rd.@ Hwy.99 City. Stoekton, CA Zip: 95205 FnniNry Confnr.t Person: Norby Contact Phone No_: (209) 931-3674 Make/Model of Monitoring System:__V1R Simplicity -_Date of Testing/Servicing: 05121103 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate speciCc equipment inspected/serviced: Tank ID;_01 -Regu 1 anK Ill: 02-Prem 29 In-Tank Gauging Probc, Model: VR 847590.108 [g In-Tank Gauging Probe. Model: VR 4473904o9 a Annular Space or Vault Sensor. Model; VR 794380301 ® Annular Space or Vault Sensor, Model: VR 794380.321 99 Piping Sump 1'I'ranah Scn2or(9). Model; VR 70480D.206 ❑ Pipiug Sul ir 1 Ti(:noh Sensur(s). Model: VR 794smu,zus ❑ Fill Sump Sensor(s). Model; None ❑ Fill Sump Sensor(s). Model: Nona ❑ Mechanical Linc Lcal(Detector. Model: None q Mechanical Linc Leak Detector. Model: None lig Electronic Linc Leuk Detector. Model; VR Series 8464 99 Electronic Linc Leak Detector, Modal. VR nodus 8444 ❑ 'Tank Ovci-ill\High-Level Scnsur. Model: None ❑ 'yank Overfill 1 Iligh-Level Sensor. Model: None ❑ Odor(specify equipment type and model in Scction E on Page 2), ❑ Other(specify equipment type and model in Section E on Pagc Z). Tank ID, TanklD- 0 in-Tank Gauging Probe. Model;?_. ❑ [n-Tank Gauging Probe, Model: ? ❑ Annular Space or Vault Scnsor, Model: ? ❑ Annular Space or Vault Sensor, Modcl: 4 ❑ Piping Sump 1 Trcnch Sensor(s), Model: ? ❑ Piping Sump\Trench Sensor(s). Model; 7 ❑ Fill Sump Sensor(s). Model: ? ❑ Fill Sump Sensor(s), Model; 7 ❑ Mechanical Line Leak Detector. Modcl: ? ❑ Mechanical Line Leak Detector. Model: 7 U Electronlc Line Leak Uetcctor. Model: 7 _. ❑ Electronic Line Leak Detector. Model: ? ❑ Tank Overfill 1 l ligh-Level Sensor. Model; ? ❑ Tank Overfill 1 High-Level Sensor. Model: 7 ❑ Other(specify equipment type and model in Scction E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2), Dispenser ID: 01.02 Dispenser ID- 03.04 ® Dispenser Cumainment Sensor(s). Model; VR 794380-322 M Dispenser Cnntainnient Sensor(a). Model: VR 794340328 09 Shear Valve W. 09 Shear Vahrc(6). ❑ nispenser Con[ainment Plnat(s)snd Chain(s}. ❑ Dispenser Contuinment Float(s)and Chain(w). Dispenser ID. 0"G Dispenser ID- 07-08 N Dispenser con[ainment Sensor(s). Model: VR 754339.322 3 Dispenser Containment Sensor(s). Model: VR794M-322 0 Shear Valve(s), 01 Shear Valve(s), ❑ Dispenser Containment Float(s)and Chain(s}_ ❑ Dispenser Containment Float(s)and Chain(s), Dispenser ID' Dispenser ID: ❑ Dispenser Containnicnt Srnsor(s). Model; ❑ Dispenser Containment Sensor(s), Model: ❑ Shear Valve(s). ❑ Sbcar Valvc(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 hispected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is fnforination(e.g.manufactures'checklists)necessary to verify that this iutLrmatiun is carrect 2110 a Plot Platt snowiuk tiic Layout at monitoring equiptnont, For any equipment capable of generating such reports.I have also attached a copy of the; (check rill chat apply): ❑ System set-up ❑ Alarm history report Technician Name(print):SSS-RonW Signature:_Ori ig nal on file at SSS Certification No.: 294-62-0088 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: 05121/03