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07/24/2003 12:44 4089710la5 SSS INC PAGE 02 <br /> Monitoring System Equipment Certification <br /> For Use 13y All Jzrrisdictions Within The State of California <br /> ,luthority Cited: Chapter 6,7,health and Safety Code; Chapter 16, division 3, Title 23, California Code of f�ogt�lations <br /> This form must be used to docluncnt testing and servicing of monitoring equipmentA separate certification or report must be <br /> nren red far each monitorin=systettt control naneby the technician who perrorins the work.A copy of this form must be provided <br /> to the taDk system 0Nv'1er/Cfg.UserName. 'i'he owzlCr/Cfg.UserName must submit a Copy of this form to the local agency regulating UST <br /> within 30 days of test date. <br /> A. General information <br /> Facility Nalne:Grant Line Shell Bldg.No.: <br /> Site Address: 2375 W. Grant Line 21-205 City: Tracy, CA Zip: 99876 <br /> Facility Contact.Person: Bill ConWCt Phunc No,; 200) 836-8908 <br /> Make/Model of Monitoring System: V/R Simplicity Date of T'esting(Servicing: 06/03/03 <br /> B. Inventory of Equipment Tested/Certified <br /> Cheek the appropriate boxes to imlicate 9pecafic equipment inspected/serviced t <br /> Tatty ID <br /> 01-Regi LTjnkD• 02-Plus <br /> �► In- hank Gauging Probe. Ntodel: VR aa799ato7 aillc C�uging Probe. Modci: VR®473go X07 <br /> og Am,nlar Space or Vault Scncor. Model: VR 794380-WI lar space or vault Sensor. Modal: VR 794380.901 <br /> Qg Piping Sump\Ticnch Sensor W. Mode]; VR 7943e0-35z Sump\'Creneh SeVt9or(s). Model: VR T84350-33Z <br /> 13 Fill Sump Sensor(s). Model: None mp Sensor(a). Model None _d Mechanical Line Leak DuAcclor, Model: None tnicall Lino Leak Dctodor. Model: None <br /> 09 Electronic Line Lcak Detector. Model: VR series a4a4 onlc Line Leak Detcvwt- Mockl: vrt Cerlo�ene4 <br /> n Tank Overt111 Iiigh-L'vclSensor. Model: None Overfill\Higb-l.cvei Sensor. Modrl: None <br /> 0 Other(specify equipment type and model in Section E on Page 2). (speedy equipment type and inodel in Section'E on Page 2). <br /> L <br /> D• <br /> 03-Prem Tank ID• 04-Diesel <br /> ank Gauging Probe. lvlodel: VR 547394-+a7 11 in-Tank Gauging Prohc. Nl;adel: VR 847390-107 <br /> AMD] Space or Vault Sena- Mock]: yn 7o4aw 301 _ 0 Annular t`les nr Vault Sen.¢or. Model; VR 794300.909 _ <br /> Sutt1P\Trench Sensor W. Model: VR 79438x•952 N Piping Sump\Trench Scnsor(s). Model: VR 794950-352 <br /> ump Sensor(S). Model: None ❑ Fill Sunup Sensor(s), Model: Now, <br /> an icat Linc Leok Dotamor. Model: wnnn ❑ Mechatlical t.inc Leak Detector, Medal: None <br /> unic Lute L,cak.Detector. Model' VR 04848-001 go Electronic Line Leak Detector. Model: VR 849490.003 <br /> Overfill\Aigh-Level Sumor. Model: None a 'Tank Overfill\High-Level Sensor. Model! None <br /> (epecilt,equipmml lype.anct model in Section E oil Page 2). 0 Other(Spt%ify equipment type and model ill Scction E on Page 2). <br /> Dispenser ID 0102 Dispenser TD- 034Q4 <br /> ❑ Dispem.er containment.Setlscor(s). Model: Nona ❑ Disposer Containment Sensor(s). Model: None _ <br /> Slz`ar Valve(s). Ri Shear Valve(H). <br /> Dispemer Containment Float(s)and Chain(s). 11 Dispenser Containment Float(s)and Chain(S). <br /> Dnsppcnsel TD nsa1s Diffppenser <br /> LspIll. 07-08 <br /> [a Denccr Containment Sensor(S). Mmiel: Nam (a Dispenser Containment Sensor(s), Model: None <br /> sbeaT Valve(Q), a Shear Valva(C). <br /> ® Mgpemer Containment Float(s)and chain(s), 01 Dispensar Containment Float(s)and Chain(a). <br /> Dispenser ED- 09-111 Dispenser til• 11-12 <br /> ❑ Dispenser Containnicnt Sensor(s). Modcl: None a Dispenser Containment Sensor(s). Model: Nene <br /> QQ Shear Valve(s). 0 shear Valvc(e). <br /> Disponscr Corrtainm6nt Float(s)and Chain(s), 09 Dispensers Containment Float(s)and Chain(s). <br /> elf tbd f:ci.lity contains more tanks or dispensers,copy t1lis'1'orn1.Include itrlornlation Por every tank and disptxuer at the facility <br /> C. Certification- I cortitty that the etildpinent identified in t11is doemnent was inspected/3ersriced in accordance with the <br /> manufacturer's guidelines. Attached to this Certification is ini'ormation(e.g-manufactures'checklists)necessary to verify that this <br /> anuation is correct and a Plot Phil 8110"Ing the layout ofmorittoring cquipiltenL For any equipment capable of gcneruting such <br /> reports,I have also attache)a copy or the. (check all nkat apply); ❑ Sy9tem set-up ❑ Alarm history report <br /> Tecluiician Namc(print):SSS-RonW Sig=talrc: Original an file at SSS <br /> C-'otitic-atinn No.: 290-62-0098 License,No.: 485184 <br /> Testing Company Name:Ser. Sta. Sys. Phone No.: (408) 971-2445 <br /> Site Address: 2379 W. Grant line&1-2015 Date of Testing/Servicing: 06/03/03 <br />