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Monitorir# Systemi et certification 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 equipment. A separate certification or report must be prepared for each monitoring system control panelby 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 systems within 30 days of test date. A. General Information Facility Name: Yosemite Shell Bldg. No. Site Address: 1330 E. Yosemite @ Highway 99 City: Manteca, CA Zip: 95336 - Facility Contact Person: Vince Make/Model of Monitoring System: V/R TLS -350 B. Inventory of Equipment Tested/Certified Check the aooronriate boxes to indicate specific equipment inspected/serviced: Contact Phone No.: (209) 825-0332 Date of Testing/Servicing: 02/26/02 Tank IDL0l - Regular Tank ID• 02 - Premium IN In - Tank Gauging Probe. Model: VR 847390.109 99 In - Tank Gauging Probe. Model: VR 847390.109 Annular Space or Vault Sensor. Model: VR 794390.409 Cg Annular Space or Vault Sensor. Model: VR 794390.409 Q9 Piping Sump \ Trench Sensor (s). Model: VR 794380.352 IS Piping Sump \ Trench Sensor (s). Model: VR 794380.352 99 Fill Sump Sensor (s). Model: VR 794380.208 (i9 Fill Sump Sensor (s). Model: VR 794380.208 Cg Mechanical Line Leak Detector. Model: Vaporiess LD2000 Mechanical Line Leak Detector. Model: Vaporiess LD2000 ❑ Electronic Line Leak Detector. Model: gone ❑ Electronic Line Leak Detector. Model: None ❑ 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 IDL23 - Diesel Tank ID• ❑ In - Tank Gauging Probe. Model ? ® In - Tank Gauging Probe. Model: VR 847390.109 ® Annular Space or Vault Sensor. Model: VR 794390.409 ❑ Annular Space or Vault Sensor. Model: ? ® Piping Sump \ Trench Sensor (s). Model: VR 794380-352 ❑ Piping Sump \ Trench Sensor (s). Model: 7 ® Fill Sump Sensor (s). Model: VR 794380.208 ❑ Fill Sump Sensor (s). Model: ? ® Mechanical Line Leak Detector Model Vaporiess LD2000 p Mechanical Line Leak Detector. Model ? ❑ Electronic Line Leak Detector. Model: None ❑ Electronic Line Leak Detector. Model: ? p Tank Overfill \ High -Level Sensor. Model: None ❑ 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• 01-02 Dispenser ID- 03-04 ® Dispenser Containment Sensor (s). Model: VR 794380.322 29 Dispenser Containment Sensor (s). Model: VR 794380.322 0 Shear Valve (s). 2g Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser I 1. 05-06 Dispenser ID- 07-08 N Dispenser Containment Sensor (s). Model: VR 794380.322 I$1 Dispenser Containment Sensor (s). Model: VR 794380.322 Shear Valve (s). IN Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID- 09-10 Dispenser ID- 11-12 j8 Dispenser Containment Sensor (s). Model: VR 794380.322 99 Dispenser Containment Sensor (s). Model: VR 794380.322 29 Shear Valve (s). 99 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 -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: 02/26/02