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Y _V' Monitorin(PSystem Equipment 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 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 Name: Fremont St. Shell Site Address: 2494 E. Fremont St. (c) Filbert St. Facility Contact Person: Mike Make/Model of Monitoring System: V/R Sim B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Bldg. No.: City: Stockton, CA Zip: 95205 Contact Phone No.: (209) 941-8743 Date of Testing/Servicing: 5/25/04 Tank ID: 01-Regu Tank ID: 02 -Prem ❑ In - Tank Gauging Probe. Model: VR 847390.109 ❑ In - Tank Gauging Probe. Model: VR 847390.109 N Annular Space or Vault Sensor. Model: VR 794380-302 Qg Annular Space or Vault Sensor. Model: VR 794380-302 N Piping Sump \ Trench Sensor (s). Model: VR 794380-208 Cq Piping Sump \ Trench Sensor (s). Model: VR 794380-208 ❑ Fill Sump Sensor (s). Model: None ❑ Fill Sump Sensor (s). Model: None ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None C9 Electronic Line Leak Detector. Model: VR series 8484 99 Electronic Line Leak Detector. Model: VR Series 8484 ❑ '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 -Waste Oil Tank ID: ❑ In - Tank Gauging Probe. Model: None ❑ in - Tank Gauging Probe. Model: ? ® Annular Space or Vault Sensor. Model: VR 794380.301 ❑ Annular Space or Vault Sensor. Model: ? ❑ Piping Sump \ Trench Sensor (s). Model: None ❑ Piping Sump \ Trench Sensor (s). Model: ? ❑ Fill Sump Sensor (s). Model: None ❑ Fill Sump Sensor (s). Model: ? ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: ? ❑ Electronic Line Leak Detector. Model: None ❑ Electronic Line Leak Detector. Model: ? ® Tank Overfill \ High -Level Sensor. Model: VR 794390-420 ❑ 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 9 Shear Valve (s). 99 Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 05-06 Dispenser ID: 07-08 Qg Dispenser Containment Sensor (s). Model: VR 794380.322 Qq Dispenser Containment Sensor (s). Model: VR 794380.322 Q9 Shear Valve (s). 99 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: ? ❑ 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). -u the tacility contains more tanks or dispensers, copy this form. Include intormation for every tank and dispenser at the facility C. Certification - 1 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-RIckD Signature: Yz_/141_�_ Certification No.: 000-00-3571 License. No.: 485184 Testing Company Name: Ser. Sta. Sys. Site Address: 2494 E. Fremont St. (@ Filbert St. Phone No.: (408) 971-2445 Date of Testing/Servicing: 5/25/04