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10(6112002 15:23 4089710135 555 IFJC PAGE 01 Monitoring ,ystem Equipment GAifxcation =� For Use By All Jurisdictions Within The State of Cahfornia w Authority Cited: Chapter 6.7,Health and Safety Code; Chapter 16,Division 3, Title 23, California Code of Regulations i 0 3 2002 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be 110AGUIN COUMTY prgimed for each monitoring system control panel by the technician who perfottns the work.A copy of this form must be provided .tc 3iatlVi,r SERUICi to the tank system owner/operator. The owner!opetator mwt submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facdity Name• Marigold Shell _ Bldg.No.: Site Address: 6131 Pacific Ave.C Porter City: Stockton, CA Zip. 95207 FduL'ty Contact Pcra'otL Kedriek Contact Phone No.: (203)9524862 Make/Model of Monitoring System: VIR Simplicity Date of Testmg!Servicing: 49/19101 B. Inventory of Equipment Tested/Certified Chock the appropriate boxes to Indicate specific epaiptsent hypaCIemservieed: Tank ID-m.Rnpu __ Tank ID- uz-Plus ❑ in-Tank Gauging(rout. Multi. vs sersaa-tor ❑ in-Tank Gauging Probe- Model vR te7sto-ion pp Annular Space or Vault Sensor. Model: vR 7l43teati ® Annular Sparc or Vault Sensor. Modcl: YR T94NO- z ® ripntg bump\ i mncn tensor(s). Model: WN rwxua3z 0 Piping Sump\Trench Senior(s). Model: vN rusaao.3w ❑ Fill Sump Sensor(s), Modcl: Nen. Q Fill Sump Sensor(s) Model: Nene ❑ Mechanical Linc L.cak Detector Modcl: Nona ❑ Mechanical Gine Ltak Detector. Model: None 99 Electronic tine Least Detector. Model; va sense new I9 fslecrronlc Linc Lcak Dctccwr. MOW: vR*KIDS a++ ❑ Tank Overfill\Nigh-Level Sensor Model: None q Tank Overfill\High-Level Sensor. Model: Nona ❑ Othcr(specify cqu►pmcm type and model in Section E on page 2)- ❑ ostia{specify equipment type and model in Section E on Pago 2). Tank 10- 03-Prism Task 1D- 0 In-Tank Gauging Probe. Model: vat 0417380-187 ❑ in-Tank Gauging Probe. Model: 7 M Annular Space or Vault Sensor. Model: VR VU380A91 ❑ Aiinalar Space Or Vault Sensor. Model:. ? 2 Piping Sump\Trench Sensor(s). Model: VR"43804U ❑ Piping Sump\Trcnch Sensor(s). Model: 7 ❑ Fill Sump Sensor(s). Model: Na» ❑ Fill Sump Sensor(s). Model: ? ❑ Mechanical Linc Leak Detector. Model: None Q Mechanical Ltne Look Detector. Model: 7 0 Electronic Line Leak Detector. Model: yR It teat ❑ Electtvnic Line teak Detector. Model: 7 ❑ Tank Overfill\High-Level Scnsor. Modcl: Non. Q 'tank Overfill\High-Level Sensor Model: 7 ❑ Other(specify equipment type and model in Section E an Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID- 01-02 Dispenser M- 03-04 ❑ Dispenser Containment Sensor(t). Model: Nate O Dispenser Containment Sensor(s). Model: Na» 0 .Shear Val. (a). O Ebur Vat.c(a). 0 Dispenser Containment goat(s)and Chain(s). O D apenca Containment Float(c)and Chain(s). Dispenser m- 05-06 Dispenser>D- 07-08 ❑ Dispenser Containment Sensor(s). Male] 7 ❑ Dispense Containment Sensor(s). Model 7 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser 1D: Dkpemer m: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: p Shear Valve(c). p Shear Valve(s). Q Dispenser Containment Flora(s)and Chain(s). ❑ Dispenser Commtmcat Float(s)and Clain(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 cerdfy that the t"Iptuesit MwiBcd in this document was iaapectedhervieed in accordance with the manalacturer's guidelines. Attached to this Certification is intoraoatins(e g.oansfamares'checkYws)secretary to verify that this Information Is correct and a Plot Man showing the layout of monitoring equipment For any equipment capable ortencrating such reports,I have also attached a copy of the, (check all riw apply); Q Systers set-up Q Alarm history report Technician Name(print):SSStilosh Signature: Original on file at SSS CcrtificationNo.. 552-61-6176 Liccmw.No.: 485164 Testing Company Name: Ser.Sta.Sys. Phone No.: (408)971-2445 Site Address: 6131 Pacific Ave-@ Porter Date of Testint;/Servicmg: 09/19101