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r' MonitorinWystem Equipment Olertirwation 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 Codes o egulation ;, This form must be used to document testing and servicing of monitoring equipment. A sgparate certification or re orN/3° st be'. prepared for each monitoring_ system control panel by the technician who performs the work. A copy of this form must be rTfided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST Wstems within 30 days of test date. A. General Information Facility Name: Shell 136186 Bldg. No.: Site Address: 3725 Tracy Blvd. @ 1-205 City: Tracy, CA Zip: 95376 Facility Contact Person: Joshua Contact Phone No.: (209) 835-7608 Make/Model of Monitoring System: V/R Simplicity Date of Testing/Servicing: 05/08/02 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID• 01 - Regu Tank ED: 02 - Plus 09 In - Tank Gauging Probe. Model: VR 847390.109 09 hi - Tank Gauging Probe. Model: VR 847390.109 N Annular Space or Vault Sensor. Model: VR 794380.301 Ig Annular Space or Vault Sensor. Model: VR 794380.301 gl Piping Sump \ Trench Sensor (s). Model: VR 794380.352 Ig Piping Sump \ Trench Sensor (s). Model: VR 794380.352 ❑ Fill Sump Sensor (s). Model: None ❑ Fill Sump Sensor (s). Model: None ❑ Mechanical Line Leak Detector. Model: None ❑Mechanical Line Leak Detector. Model: None Ig Electronic Line Leak Detector. Model: VR 331196.001 Qg Electronic Line Leak Detector. Model: VR 331198.001 ❑ 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 ® In - Tank Gauging Probe. Model: VR 847390.109 gj In - Tank Gauging Probe. Model: VR 847390.109 ® Annular Space or Vault Sensor. Model: VR 794380.301 INAnnular Space or Vault Sensor. Model: VR 794380.301 ® Piping Sump \ Trench Sensor (s). Model: VR 794380.352 99 Piping Sump \ Trench Sensor (s). Model: VR 794380.352 ❑ Fill Sump Sensor (s). Model: None ❑ Fill Sump Sensor (s). Model: None ❑ Mechanical Line Leak Detector. Model: None ❑Mechanical Line Leak Detector. Model: None ® Electronic Line Leak Detector. Model: VR 331196-001 Qg Electronic Line Leak Detector. Model: VR 331196.001 ❑ 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 19 Shear Valve (s). IN Shear Valve (s). Ig Dispenser Containment Float (s) and Chain (s). jg Dispenser Containment Float (s) and Chain (s). Dispenser ID- 05-06 Dispenser ID: 07-06 ❑ Dispenser Containment Sensor (s). Model: None ❑ Dispenser Containment Sensor (s). Model: None 09 Shear Valve (s). 99 Shear Valve (s). Qg Dispenser Containment Float (s) and Chain (s). 99 Dispenser Containment Float (s) and Chain (s). Dispenser ID- 09-10 [DispenserID- 11-12 ❑ Dispenser Containment Sensor (s). Model: None ❑ Dispenser Containment Sensor (s). Model: None 99 Shear Valve (s). Ig Shear Valve (s). Qg Dispenser Containment Float (s) and Chain (s). 09 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 -Josh Signature: Original on file at SSS Certification No.: 552-61-6176 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: 05/08/02