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05/07/2003 16:20 40897laL35 SSS INC PAGE 02 Monitoring System Equipment Certification For Use By All Jurisdictions Within 7hc. State of Cal forrria Authority Cited, Chapter 6.7. Health and Safety Code; Chapter -1 G, Division 3, Title 23, Califomia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared far each monitoring system coritrolTanelby the technician who performs the work. A copy of this form must be provided to the tank system owner/Cfg.lJscrName. The owner/Cfg.UserName must submit a copy of this form to the local agency regulating UST s. within 30 days of test date. A. General Information Facility Name: Yosemite Shell BIdg. No.: Site Address: 1330 E. Yosemite @ Highway 99 City: Manteca, CA —Zip: 95336 - Facility Contact PUIbUit: Theresa Contact Phone No.: 5209) 826-0332 Make/Model of Monitoring System: VIR TLS -350 Date of Testing/Servicing. 419103 B. inventory of Equipment Tested/Certified Cheek the annronriate boxes to indicate sDecific equipment inspected/serviced: Tank ID• 01 - Regis Tank LD• 02 -Prem ❑ in - Tank (.iauging Probe. Model: VR 847390.109 _ ❑ in -Tank Gauging Probe. Madel: VR 847380.10 Cg Annular Space or Vault Scnsor. Model: VR 794390.409 9 Annular Space or Vault Sensor. Model: VR 794390.409 Qg Piping .•iurnp'% rrcnch Sensor (s). Modul: vrc rmns::o.3s2 tg Piping Sump \ Ttcocl, ivasul W. Model; vR?*4t+00-oat C§ fill Sump Sensor (s). Model: VR 794380-352 S Fill Sump Sensor (s). Model' VR 794980.352 IS Mechanical Line Leak Detector. Model: Vacorless L02000 119 Mechanical Line Lcak Detector. Model: Vaporlesss L02000 U Electronic Linc Leak Detector. JvJU&l• Nom I Cl electronic Linc Leak Detector. Model: Nona ❑ Tank Overfill 1 Iligh-Level $Cnsnr. Model: None ❑ Tank Overfill \ Nigh -Level Sensor. Model: Norte ❑ Other ( specify equipment type and model in Section E on .Page 2). 1103 Other ( specify equipment type and model in Section E on Page 2). Tank 1D• 03 - Diesel _ Tank ID° ❑ In - Tank Gauging Probe. Modcl: VR847390-109 _ ❑ In -Tank Gauging Probe, Model: 7 M Annular Space or Vault Sensor. Mule/: VR 7,94390.409 ❑ Annular Space or Vault Sensor. Model; ? 0 Piping Sump 1 Trench Sensor (s). Model; VR 794389.352 ❑ Piping Sump \ Trench Sensor (s). Modcl: ? 11 Fill Sump Sensor (s). Model: VR 794380-352 .-. ❑ Fill Sump Sensor (s). Model: 7 01 Mechanical Line Lcak Detector. Model: Va2orless_L02000 ❑ Mechanical Lino I.,cak Detector. Model: ? 0 Electronic Line Leak Detector. Modcl: None p Flectmnic Line Leak Detector. Model: ? ❑ Tank Overfill \ High -Level Sensor. Model: None ❑ Tank Overfill N High -Level Sensor. Model: ? ❑ Other ( specify equipment type and model in Section L• on Page 2). ❑ Other ( specify equipment type and model in Section E on Page 2). 01-02Dispenser ID03-04ntainment 7M,pense�rflD- Scnsor (s). Model: 0794390.322 IS Dispenser Containment Sensor (s)- Model: vR 794380-322 29 Shear Vatvc (a). ntainment Float (s) and Chain (s), ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 05-06 Dispenser IDD- 07-08 IN Dispenser Containment Sensor (s). Model' VR 7114380-322 In Dispcnser Containment Sensor (s). Model: VR 794380.322 $1 Shear Valve (s). 0 Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). Q Dispenser Containment Float (s) and Chain (s)• Dispenser ID- 09-10 Dispenser ID; 11-12 C9 Dispenser Containment Scnsor (s). Model: VR 794380.322 lig Dispenser Containment Sensor (s). Model: VR 794380.322 M ghrstr Vaive (c). lig Shear Valve (s). ❑ Dispenser Contailm ent 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. Certifleation — I certify that the equipment identified in this document was inspecteNservited in accordance with the manufacturer's gnidellaes. Attached to this Certification is information (e.g. manufactures- checklists) necessary to verify that this Information is correct anis/ a Plot Plan showing the layout of monitoring equipment. Far any equipment tapable 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-Chris Signature: Original on file at SSS Certification No.: 566.95-8259 License, No.: 485184 Testing Company Name: Ser. Sta. Sys. - Phone No.: (408) 971-2445 Site Address: 1330 E. Yosemite @ Highway 99, _ Date of Testing/Servicing: 419103