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JAN-11-2005 21:14 SERVICE STATION SYSTEM 408 971 0135 P.06 Monitorinj Systemi e t fertification Por Use By All Jurisdiction.• Within The State of California Authority Citeel: Chapter 6.7,Health and,Sa}ety Cade; Chapter 16,Division 3, Title 23, California Code.o Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or repot-t must be prepared for each monitori? system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST system within 30 days of test date. A. General Information Facility Nanic: i2iRon Sheii -- Bldg,No.: Site Address: 341 E. Main St. a Hwy.99 City. Ripon, CA Zip: 95366 Facility Contact Person: T__. Contact Phone No.: (209) 599-4454 Make/Model of Monitoring System: V/R Simplicity Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified �l711q' Check the appropriate hoxes to indicate specific equipment inspected/serviced: Tank ID•01-Reg. Tank ID• 02-Prem ❑ In-Tank Gauging Probe. Mudel: VR 847390.109 13 in-Tank Gauging Probe. Model: VR 847390-109 ❑ Annular Space or Vault Sensor. Model VR 794380.102 ® Annular Space or Vault Sensor. Model: VR 794380.302 p Piping Sump\Trench Sensor(s). Model: VR 794380-208 ❑ Piping Sump\'french Sensor(s), Model: VR 794180-208 (3 Fill Sump Sensor(s). Model: None ❑ Fill Sump Sensor(s). Model; None ❑ Mechanical Linc Leak Detector. Model' None ❑ MechanicaI Linc Leak Detector. Model: None Electronic Line Leak Detector. Model: VR Series 2424 Electronic Line Leak Detector. Model: VR Series 8494 Q Tank Overfill\High-Level Sensor. Model: None ❑ Tank Overfill\High-Level Sensor, Model: Nona ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Sectiun E on Page 2) Tank 1D' Tank ID: ❑ In-Tank Gauging Probe. Model; ? p in-Tank Gauging Probe, Model: ? _ ® Annular Space or Vault Sensor. Model: ? El Annular Space or Vault Sensor. Model: 7 ❑ Piping Sump\Wrench Sensor(s), Model: ? ❑ Piping Sump\Trench Sensor(s). Model: ? ❑ Fill Sump Sensor W. Model: ? ❑ Fill Sump Sensor(s). Model: 7 ❑ Mechanical(Arc Leak Detector. Model: ? ❑ Mechanical Litre Leak Detector. Model ? ❑ Electronic Linc Leak Detector. Model: 7 Q Electronic Line Leak Detector. Model: ? Q Tank Overfill\High-Level Sensor. Model: ? ❑ 'Tank Overfill\High•Level Sensor, Model: ? C) Othcr(Specify eyuiprlleflt type and moCc1 in;Section;L:on Nage 2), O Other(specify eyuipilient type and model in Scam F.On Page 2). Dispenser ID: 01.02 Dispenser ID; 03.04 ❑ Dispenser Containment Sensor(s), Model: VR 794380-322 ❑ Dispenser Ccmtainment Sensor(S). Model: VR 794380-322 Ll 13 Dispenser Containment Float(s)and Chain(s). p I)ispenser Containment Float(s)and Chain(s). Dispenser ID, 05-06 Dispenser ID- 07-08 ❑ Dispenser Containment Sensor(s). Model; VR 794180.322 Ll Dispenser Containment Scnsnr(s). Model: VR 754390.322 ❑ Shear Valve(s), [3 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s), Dispenser J[D; Dispenser ID, ❑ Dispenser Containment Sensor(s). Model: 7 1 n Dispenser Containment Sensor(s). Model: 7 A 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 fonn.Inchtdc information for every tank and dispenser at the facility C.Certification- I certify that the equipment identified in this document was Inspectediserviced 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,l have also attached a copy of the; (check all that appl,V)- [3 Systemset-up C Ain istory report Technician Name(print)-S6S--Rrl"cTc U5 Vic .. - Signature: Certification No,- _ C)(J.`{.JS—L_ License.No. 5184 Testing Company Name: Ser. Sta.SYS, Phone No. 408)971-2445 Site Address: 341 E. Main$t.!M Hwy. 99 __ Date of Tcsting/Servicing,,,��`j