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10/10/2002 15:30 4089710 '�5 SSS INC PAGE 02 Monitoring System Equipment Certification 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, Cal fornia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A sCRaTate certification or re ort mut 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 task systoill owucr/upc:ratt i:. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General bif'ormatlon Facility Name: Marigold Shell Bldg.No.: Site Address: 6131 Pacific Ave.@ Porter _ City: Stockton, CA Zip: 95207 Facility Contact PerRon• Rigul Contact Phone No.. 209 9524862 Make/Model of Monitoring System: V1R Simplicity - - Date of Testing/Servicing: 9124102 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank 1313101 -Rogu Tank 1D- 02-PIus Qg !n-'tank Gauging Probe. Model: vR347890.107 99 In-Tank Gauging Probe. Model: VR847390.107 Q9 Annular Space or Vault Sensor. Model; VR 7942ea-302 Qg Annular Space or Vault Sensor. Model: VR 794380-302 DQ Piping Sump\Trenoh Sonsar(a). Model: yn 7*4�*0-3U 99 Piping 5ump\Trench',Cn5or(s). Model: VR 794980.952 ❑ Fill Sump Sensor(s), Model: None ❑ Fill Sump Sensor(s). Model: None ❑ Mechanical Line Leak Detector. Model: None 0 Mechanical Linc Leak Detector. Model: None D9 Electronic tine Teak T)ettrrtnr Model: vR%nine edea 99 Eloot"mia Linc Lcak l3cwLtuc. Model: vn'50,1•6 6909 Q Tank Overfill 1 High-Level Sensor, Model: Non* ❑ Tank Overfill 1 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. 03-Prem Tank fp* X In-'tank Gauging Probe, Madel: VR 847390.107 ❑ In-Tank Gauging Probe, Modcl; 7 2 Annular Spaec or Vault Sensor. Model; VR 7943ae-302 ❑ Annular Space or Vault Sensor. Model: 7 Ap Piping bump\Trench Sc tsor(s), Model: VR 794380.952 q Piping Sump\Trench Sensor(s). Model: 7 Cl Fill Sump Sensor(s). Model; None ❑ Fill Sump Sensor(s), Model: ? Q Mechanical Line Leak Detector, Model: None ❑ Mcclzanical Line Leak 1?etcetor. Model: ? _ a Elcctrunic Line Leak Detector. Model: VR series 8494 ❑ Electronic Line Leak Detector. Model: ? Q Tank Overfill\I-ligh-Lcvd Scttsolt Model: Nona ❑ Tank Overfill\High-Level Sensor. Model: ? ❑ Other(specify equipment type and model in Section L on Nage 2), ❑ Other(specify equipment type and model in Section E on Page 2)_ Dispenser ID: 01-02 Dispenser ID; 03-04 ❑ Dispenser Containment Sensor(s). Model: None ❑ Uispc»ser Containment Sensor(s). Model: None 29 Shear Valve(s). IN shear Val,•a(a)- 1§ Dispenser Containment Float(s)and Chain(5), 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: Os•os Dispenser ID-- 07-06 ❑ Dispenser Containment Sensor(s). Model: Nona ❑ Dispenser Containment Sensor(s)-7 Model: None 99 Shoar Valve(s). s Shear Valve(s), M Dispenser Containment Float(5)and Chain(s). lig Dispenser Containment Float(s)and Chain(s). 7Dispenser Dispenser IDs. tainment Sensor(s). Model; ❑ Dispenser Containment Sensor(s). Model; s). ❑ Shear Valve(s). tainment Float(s)and Chain(s), p 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(c.g.manufactures'checklists)necessary to verify that this infarmahnn is correct*"a.Plvt Pini shuwing the layout of monitoring equipment. For any equipment capable of generating such reports,f have also attached a copy of the; (cheek all that apply: ❑ System set-up ❑ Alarm history report Technician Name(print):555-Chris Signature:_Original on file at SSS Certification No.: 566-95-8259 Lieensc-No.: 485184 Testing Company Name: Ser. Sta.Sys. _ Phone No.: 40$ 971-2445 Site Address: 6131 Paeltie Ave. port®r _ Date of Tcsting/Servicing: 9124102