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MOnitOOng System Equipme ft Certifleation For Use By All Jurisdictions Within The State ofCttefornia Authority Cited: Chapter 6.' Fleakh and Saferr Code; Chapter 16, Division 3, Title 23, California Code ofRegulatiors This form must be used to document testing and servicing of monitoring eq ' re a-ed for ach nitotin s stem control anel by the technician who p anion r re o mus be to the tank system owner/operator. The owner/operator must submit a copy of this form to the local a en form must be provided within 30 days of test date. SEP _ 6cy regulating UST system A. General information 6 2005 Facility Name:Marigold Shell ENVIRONP,IEadT HEA Lri-I PERti11T /SE 1 Bldg,No.: Site Address: 6131 Pacific Ave. @ Porter Cit„ : Stockton, CA Zlp; 95207 _ Facility Contact Person: Kendrick Contact Phone No.: (209)952-4862 Make/Model of Monitoring System: V/R Simplicity Late of Testing/Servicing: 10/7104 B. Inventory of Equipment Tested/Certified Cheek the appropriate boxes to indicate specific equipment impectad serviced: Tank ID:0'•-Regu OZ-Plus rTank 1D: ❑ !n•Tank auging?tubo ocel: ori J47390-to7 0 in-Tank Gau in Annular Space or Vault Sensor. 'model: VR 7943-30-302 M Ag 8 Probe. iv:o e[: VR 647390.107 j Annular Space or Vault Sensor, Model: VR 794da0 F02 i Piping Sump 1 Trench Sensor(s). Model: VR 7943-30-352 �I Piping Sump 1 Trench Sensor(s). Model: VR 79QBOo ZS2 I! [] Fill Sump Sensor(i). Model: None Fill Sum Sensor(s),❑ Vlcchacical Line Leak Detector. Model: None I p O Model: Non. I+ ❑ Ivlecltartical Linc Leak Detector. model: +46n. ! Electronic Line Leak Detector, Model: VR s.rlee 3484 - I6 Elcctronic Line Leak Detector. Model: VR series a4a4 ! ❑ Tank Overfill 1 Fiigh-bevel Sensor. Model: None I (j Tank Overfill'High-Level Sensor. Model: Non. I �1 ❑ Other(specify equipment type and mode'in Srction E on Page-)• Other(s a 11n equi Lent !i j ❑ P p• p'pe and mode n Section;on Page-), Tank ID: 03-Prem I Tank®: i ❑ In•T auging Probe. Moael: vR 347390-107 ❑ In-Tank Gauging robe. model: 7 Annular Space or Vault Sensor. Model: V R 7943soao2 ❑ Annular Space or Vault Sensor. Mudcl 9 j Piping Sump 1 T=6 Sensor(s). Model: VR 794380-332 f ❑ ?iping Sump Trench Serscr(s). Model: 7 I ❑ Fill Sump Sensor(s) Mode:: None FiIJ Sun oensor s). —�— j ❑ Mechanical Line Leak Detector. Model: Non. P ( Model: 7 ❑ Mechanical Line Leak Detector. Model: 7 Electror>ic Lino Leak Detector. Modci; VR series saes ❑ Electmrt c Line Irak Detector. Model: 7 Tank Overfill 1 High-Level Sensor. b:odei: Nano ❑ Tank Overfill',High-Level sensor. Model: 0 Other(specify equipment type and model is Section E on Page'_). ❑ Other(specify equipmen',type and model in Section E on Fage c). Dispenser ID: 01-02 03.0-3 ++ Dispenser ID: (] Disperser Contaitunent Sersur(s). Model: Nen• ❑ Dspenser Containment Sensor(, ivloael: von• oll Shear Valve(s). )' Shear Vaive(s). j i� DispenserCuntainment Float(s)and Chain(s). A Dispenser Conainment Float(s)and:Thain(s). I Dispenser ID: os•os Dispenser ID: 07 G8 ❑ DispettserConta;nmentSensor(s). Model: Non. I 0 Dispenser Containme, ccuor(s). �iucel: Nee. �E Shear Valve (s). Shear Vale(s). —” Dispenser ConWnment Float(s)and Chain(s� Dispenser Containment,loaf(s)and Chain(s). II Dispenser ID: Dispenser ID: ❑ Dispenser ContammcntSensor(s). Model: 7 I ❑ DispenserContairtrtentSensor(s). Madel. 7 C: Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment F!oat(s)and Chain(s). 'lf rhe facility contains mors tanut or dispensers,copy C-is form.include information for every tank and dispense:at the facility C. Certification - I certify that the equipment identilkd fu this document was Laspected/serviced in accordance with the manufacturer's guidelines. Attached to this Ceramcation 6 information(e.g.manufactures checklists)necessary to verify that this information b correct and a Plot Plan showing the layout of munitorittg equipment• Fur any equipment capable of generating!uch reports,S have also attached a copy of the; (check as Char app:y): ❑ System set-up ❑ Al4rm history report Technician Name(print):SSS-R1ckD Signature. Certification No.: 006-05-1151 'icense.No.: 485184 Testing Company Name:Ser. Sta. Sys, Phone No.: (408)971-2445 Site Address: 6131 Pacific Ave. @ Porter Date of Testing/Servicing: 1017104