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Monitorin&*ystem Equipment Gertification For Use By All Jurisdictions Within The State of California .4ui iority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 33, California Code of Regulations This form must be used to document testing and servicing of monitoring equipmentA separate certification or report P") prepared for each monitoring system control paneby the technician who performs the work.A copy of this form must be provided to the tank system owner/Cfg.UserName. The owner/Cfg.UserName must submit a copy of this form to the local,d*cprt-" g UST within 30 days of test date. A. General Information 0, 4, JA CRANKS JE19GOW Facility Name: Tracy Blvd Shell & Mini Mart Bldg. No.: Site Address: 3725 Tracy Blvd. @ 1-205 City: Tracy, CA Zip: 95376 Facility Contact Person: Contact Phone No.: (209) 835-7608 Make/Model of Monitoring System: V/R Simplicity Date of Testing/Servicing: 06/03/03 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 01 - Regu Tank ID: 02 - Plus 99 In - Tank Gauging Probe. Model: VR 847390-109 09 In - Tank Gauging Probe. Model: VR 847390-109 Q9 Annular Space or Vault Sensor. Model: VR 794380-301 Q9 Annular Space or Vault Sensor. Model: VR 794380-301 09 Piping Sump \ Trench Sensor (s). Model: VR 794380-352 QQ Piping Sump \ Trench Sensor (s). Model: VR 794380-352 ❑ Fill Sump Sensor (s). Model: None ❑ Fill Sump Sensor (s). Model: None ❑ Meehanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None Q9 Electronic Li ie Leak Detector. Model: VR Series 8484 QQ Electronic Line Leak Detector. Model: VR series 8484 ❑ Tank Overfill \ High -Level Sensor. Model: None ❑ Tank Overfill \ 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 ID• 04 - Diesel QQ In - Tank Gauging Probe. Model: VR 847390-109 ® In - Tank Gauging Probe. Model: VR 847390-109 9➢ Annular Space or Vault Sensor. Model: VR 794380-301 Q9 Annular Space or Vault Sensor. Model: VR 794380-301 ® Piping Sump \ Trench Sensor (s). Model: VR 794380-352 Q9 Piping Sump \ Trench Sensor (s). Model: VR 794380-352 ❑ Fill Sump Sensor (s). Model: None ❑ Fill Sump Sensor (s). Model: None ❑ Meehanical Liue Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None ® Electronic Line Leak Detector. Model: VR Series 8484 Q4 Electronic Line Leak Detector. Model: VR Series 8484 ❑ Tank Overfill \ High -Level Sensor. Model: None ❑ Tank Overfill \ 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). Dispenser ID: 01-02 Dispenser ID- 03-04 ❑ Dispenser Containment Sensor (s). Model: None ❑ Dispenser Containment Sensor (s). Model: None Q9 Shear Valve (s). Qg Shear Valve (s). IN Dispenser Containment Float (s) and Chain (s). Q9 Dispenser Contaimnent Float (s) and Chain (s). Dispenser ID: 05-06 Dispenser ID: 07-08 ❑ Dispenser Containment Sensor (s). Model: None ❑ Dispenser Containment Sensor (s). Model: None 09 Shear Valve (s). QQ Shear Valve (s). QQ Dispenser Containment Float (s) and Chain (s). Q9 Dispenser Containment Float (s) and Chain (s). Dispenser ID- 09-10 Dispenser ID: 11-12 ❑ Dispenser Contaimnent Sensor (s). Model: None ❑ Dispenser Containment Sensor (s). Model: None Q9 Shear Valve (s). 09 Shear Valve (s). Q9 Dispenser Containment Float (s) and Chain (s). Q9 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 (e.g. manufactures' checklists ) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the; ( check all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print):SSS-RonW Signature: Original on file at SSS Certification No.: 290-62-0088 License. No.: 485184 Testing Company Name: Ser. Sta. Sys. Phone No.: (408) 971-2445 Site Address: 3725 Tracy Blvd. @ 1-205 Date of Testing/Servicing: 06/03/03