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07/24/2003 12:44 4089710; 5 SSS INC PAGE 03 w Monitoring System Y t Pertificatlion For Use ByA11,1urisdictions Within The State:vfCalifornia Aurhority Cited,- Chapter 67, 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 equipmentA separate certification or rgort must be nrtrnared for each monitorin s stem control aneby the technician who performs the Nvork.A copy of this fors!;must be provided to the tank system owner/Cfg.UserName_ The owner/Cfg.UserName must submit a copy of this form to the local agency rcgularing US'T within 30 days of test date, A. General Information Facility Name-Grant Luse Shell Bldg.No.: Site Address: 2375 W. Grant Line 1-205 City: Tracy, CA Zip: 95376 Facility Contact Person' Bill Comac;t.1'honc No.: (209) 836-8908 Make/Model of Monitoring System: V/R SimpliCity Date of Testing/Servicing- 06103/03 B. Inventory of Equipment tested/Certified C'lteck the appropriate boxes to indicate specific equipment fttspectcd/serviced: Tank ID Tank IIt- In-Tank Gaugin Probe. Model: ° ❑ Itt•Tank Gaugsatg Pt'ohe. Model: ❑ g n Annular Space or Fault Settlor. Model: ? q Annular Space or vault gem-or. Model: ? ❑ Piping Surnp\Trench Sensor W. Model: ? ❑ Fiping Sump\Trench Sensor(s). Manlal: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 7 ❑ Mechanical Line Lmk Det-tor. Model: ? _ ❑ Mechanical Litre Leak Detector. Model: ? ❑ Electronic Linc Leak Detector. A4odcL- ESCO X723-0002 ❑ Electrunie I!tic LcA Detector. Modol: CSOo x723-0002 ❑ Tank Overfill\Higb-Level Sensor. Model: ? ❑ 'rank Overfill\High-Level Sensor, Model: ? ❑ Other(specify,nimpttrent type and model in Section E oa Page 2). ❑ Other(specify rxluipn)ent type and model in Section E on Page 2), Tank ID. Tank ID° 14ode1.; ? [3 In-Tank Gauging Probe. Model: ? [I in-Tank Gauging Probe. y C2 Aaun6tar Spaer,or Vault Sen-lor. Model: 7 ❑ Annular Space or vault.Sensor. Model: ❑ Piping Sump 1 Trench Sensor(s), Model: ? ❑ Piping Sump\Trench Sensor(s). Model: ? (3 Fill Sutnp Sensor(s). Model: ? ❑ Fill Sump Sensor(s). Model: ? rlDispwset- ohoniwal Lino t.ea1_Detector. Mndel: ? ❑ Mechanical Line Leak Door. Model:ctronic l..inc Loak Detector. Ivlodel: Est O X7zs-0002 [] Electrons Lida Leak Detector. MOdcl: Est O x723 0002 Tank Overfill\Ri rLevel Sensor. Model: ? >k C)vcrli 111 I3igh•Level Sensor. Ntodcl: ? ❑ Sleo(specify cyuipmzrit type and mode(in Section k rnr Page ❑ Othcr(specify equipmenttype and model in Section E on Page 2). lb' 13-14 Dispellser IDL 1616 — ❑ spemser Contain nrLoot Sensor(S)- Model: None [I Dispenser Containment Sasser(s}, Model: None (!Q Shear valve(s). 3lawu Valet(s). Diapcm�er Containment Float(s)and Chain(s). MgpLmscr Contauuuent Float(s)and Chain(s). Dis Wstser ID• 17-18 Dispenser 1D: 19-20 ❑ JJ)iapcnscr Contnimnent Scnwr(s). Model: None ❑ Dispenser Containment Sensor(s). Model: None Shear Valve n Ijg Shear Valve(s). 09 pQ Dicpcns0r Containment Float(s)and Chain(s). 01Dispctt3zr Cotttainmcnt Float(s)and C11ain(s). Dispenser ID• 21-22 Dispenser ID° p Dispenser C:ontil amietrc SCttCOr(s). Model: None ❑ Dispenser Contailuncnt Sensor(s), Model: 1Z4 Shyar Valve{�). (� Shear Valva(s). ® Dispenser Containment Float(s)and Chain(s). ❑ Dispemor Containment Float(s)and Chain(s). a4fthe facility contains more tanks or dispeoi ers.copy this forn,.Include nttorntation for every tank and dispenser at the facility C. Certification- I cet't1l�that the cyulipment identified in this document was inspected/serviced in accordance w1th.the manufacturer's guidelines- ,Attached to this Cet'tification is inforntntion(e g.manttfncttires'checklists)necessary to verify that this information is correct and.u Plot Plan showing the layout of monitoring equ IrAnent. For any cgttipment capable of generodug such reports,I have also attached it copy of the; (check ail float apply): ❑ System set-up ❑ Alarnt history report Technician Name(print :SSS-Rot1W Signature'_Original on file at SSS _ Certification No.: 290-62-0088 License.No.: 483154 Testing Company Name: Ser. Sta. Sys. Phone No.: 408 971-2445 Site Address: 2375 W Grant Line 0 1-205 -Date of Tcsdnj?)5enicing:..06/03103