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MonitorinaSystem Equipment Oertification 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, California Code of Regulations This form must be used to document testing and servicing of monitoring equipmentA separate certification or report must be prepared for each monitoring system control pane)by 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 agency regulating UST within 30 days of test date. A. General Information Facility Name: Tracy Blvd Shell & Mini Mart Bldg. No. Site Address: 3725 Tracy Blvd. @ 1-205 City: Tracy, CA Zip: 95376 Facility Contact Person: Andy 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: TankID: TankID: ❑ In - Tank Gauging Probe. Model: ? ❑ In - Tank Gauging Probe. Model: ? p Annular Space or Vault Sensor. Model: ? ❑ Annular Space or Vault Sensor. Model: ? ❑ Piping Sump \ Trench Sensor (s). Model: ? ❑ Piping Sump \ Trench Sensor (s). Model: ? ❑ Fill Sump Sensor (s). Model: ? ❑ Fill Sump Sensor (s). Model: ? ❑ Mechanical Line Leak Detector. Model: ? ❑ Mechanical Line Leak Detector. Model: ? ❑ Electronic Line Leak Detector. Model: ? ❑ Electronic Line Leak Detector. Model: ? ❑ Tank Overfill \ High -Level Sensor. Model: ? ❑ Tank Overfill \ High -Level Sensor. Model: ? ❑ 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• Tank ID• ❑ In - Tank Gauging Probe. Model: ? ❑ In - Tank Gauging Probe. Model: ? ❑ Annular Space or Vault Sensor. Model: ? ❑ Annular Space or Vault Sensor. Model: ? ❑ Piping Sump \ Trench Sensor (s). Model: ? ❑ Piping Sump \ Trench Sensor (s). Model: ? ❑ Fill Sump Sensor (s). Model: ? ❑ Fill Sump Sensor (s). Model: ? ❑ Mechanical Line Leak Detector. Model: ? ❑ Mechanical Line Leak Detector. Model: ? ❑ Electronic Line Leak Detector. Model: ? ❑ Electronic Line Leak Detector. Model: ? ❑ Tank Overfill \ High -Level Sensor. Model: ? ❑ Tank Overfill \ High -Level Sensor. Model: ? ❑ 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; 13-14 Dispenser ID -16-16 ❑ Dispenser Containment Sensor (s). Model: None ❑ Dispenser Containment Sensor (s). Model: None 09 Shear Valve (s). Q9 Shear Valve (s). Ig Dispenser Containment Float (s) and Chain (s). 09 Dispenser Containment Float (s) and Chain (s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID• Dispenser ID• ❑ Dispenser Containment Sensor (s). Model: ❑ Dispetnser Containment Sensor (s). Model: ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ 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 -Ronal 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