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RUG-21-2004 17:20 SERVICE STATION SYSTEM 408 971 0135 P.02 Monitorii#System Equipment fertification For Use By All Jurisdictions Within The State of California Authority Cited: Chapter rs 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 prppared for each m ni Orin r system control panel by the technician Who performs the work.A copy of this form nlust be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systcltz within 30 days of test date. A. Generallnforination Facility Name:Marigold Shell Bldg.No.: Site Address: 6131 Pacific Ave.@ Porter City: Stockton, CA Zip: 95207 Facility Contact Person:Kenny Contact Phouc No.: (209)952-4862 MaketModel of Monitoring System: V/R Simplicity Date of Testing/Servicing: 7/26/04 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inmpected/serviced: Tank ID:01- egu Tank ID: 02-Plus C] In-Tank Gauging Probe. Model: VR 847380-107 ❑ In-'Dank Gauging Probe. Model: VR 847390-107 Annular Space or Vault Sensor. Model: VR 784350-302 6 Annular Space or Vault Sensor, Model: VR 794390 sot �§ Piping Sump 1 Trench Sensor(s), Model: VR 794380-362 15 Piping Sump 1 Trench Sensor(s). Model: VR 704390-352 C] Fill Sump Sensor(s). Model, Non. 0 pill Sump Sensor(s). Model: Mona 0 Mechanical Linc Leak Detector. Model: None p Mcohatucal Linc Lcak I)etector. Model: None Electronic Line Leak Detector. Model: VR Series 9484 Electronic Linc Leak Detector. Model: VR Serles 9484 C7 Tank Overfill l High-Level Sensor, Model: None Tank Overfill 1 High-Level Sensor. Model: Non* Othcr(spceiiy equipment type and model in Section E on Page 2). (] Other(specify equipment type and model in Section E on Page 2), Tank ID: 03-Prom Tank ID: C7 In-Tank Gauging Probe. el; VR 847300.107 0 In-Tank Gauging Probe. ModeL 7 N Annular Space or Vault Sensor, Model VR 794380302 p Annular Space or Vault Sensor. Model: ? 19 Piping Sump 1 Tronch Senior(s). Model: VR 794390-352 0 Piping Sump 1 Trench Sensor(s). Model: 7 p Fill Swap Sensor(s). Model: NoneC] Fill Sump Sensor(s). Model: 7 C] Mechanical Line Leak Detector. Madel: None chamoxl Linc Leak Detector. Model: 7 Electronic Line Leak Detector. Model: VR Series 0454 O Electronic Linc Lcak Detector. Model: 7 p Tank Overfill l Higb-bevel Sensor. Model: None p Tank Overfill\High-Level Sensor. Model: C7 Other(specify equipment type and model in Section E on Page 2). (3 Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 07-02 Dispenser ID: 03.04 Cj Dispenser Containment Sensor(s), Model: None_ C) Dispenser Containment Sensor s). o e: None 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: 07-03 0 Dispenser Containment Senior(q5. Model: Nona C7 Dispenser Containment Sensor(s). Model: None 6 Shear Valve(s). Shear Valve(s). 6 Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: t7 Dispenser Containment Sensor s). Model; 4 [] Dispenser Cotntainurent Scncor(s). Model: ? 0 Shcar Valvc(s). C3 Shear Valve(s). Q Dispenser Containment Float(s)acrd Chain(s), 17 Dispenser Containment Float(s)and Chain(s). "If the facility contains more tanks or dispensers,copy this fomi.Include information for every tank and dlspcnscr at the facility C. CertifiCAtlon- I certify that the equipment identified in this document was hispected/serviced In accordance with the manufacturer's guidelines. Attached to this Certification h information(e.g.manufactures'checklists)ncecssary to verify that this information is correct and a Plot plan showing the layout of monitoring equipment. For any equipment capable of 2encrating such reports,I have also attached a copy of the; (cheek all friar apply): 17 System set-up 0 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: 6131 Pacific Ave. @ Porter Date of Testing/Scrvicing: 7/26/04