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Monitorinoystem Equipment WrtificatioriL00w For Use By All Jurisdictions Within The State of California Authoritv Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code ofRiolotiopf.-C;7 This form mast be used to document testing and servicing of monitoring equipmentA separate certification or report must be prepared for each monitoring system control paneby the technician who performs the work.A copy of this fbitriteexstllZ�'ptoi:a to the tank system owner/Cfg.UserName. The owner/Cfg.UserName must submit a copy of this form to the local agency regulating UST within 30 days of test date. A. General Information Facility Name: Grant Line Shell Bldg. No.: Site Address: 2375 W. Grant Line @ 1-205 City: Tracy, CA Zip: 95376 Facility Contact Person: Bill Contact Phone No.: (209) 836-8908 Make/Model of Monitoring System: V/R Simplicity Date of Testing/Servicing: 06/03/03 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:01 -Regu Tank ID: 02-Plus QQ In-Tank Gauging Probe. Model: VR 847390-107 09 In-Tank Gauging Probe. Model: VR 847390-107 Q9 Annular Space or Vault Sensor. Model: VR 794380-301 QQ Annular Space or Vault Sensor. Model: VR 794380-301 QQ Piping Sump\Trench Sensor(s). Model: VR 794380-352 QQ Piping Sump\Trench Sensor(s). Model: VR 794380-352 ❑ Fill Sump Sensor(s). Model: None ❑ Fill Sump Sensor(s). Model: None ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None Q9 Electronic Line Leak Detector. Model: VR Series 8484 QQ 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-Prem Tank ID: 04-Diesel M In-Tank Gauging Probe. Model: VR 847390-107 QQ In-Tank Gauging Probe. Model: VR 847390-107 ® Annular Space or Vault Sensor. Model: VR 794380-301 Qg Annular Space or Vault Sensor. Model: VR 794380-301 ® Piping Sump\Trench Sensor(s). Model: VR 794380-352 QQ Piping Sump\Trench Sensor(s). Model: VR 794380-352 ❑ Fill Sump Sensor(s). Model: None ❑ Fill Sump Sensor(s). Model: None ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None ® Electronic Line Leak Detector. Model: VR 848480.001 QQ Electronic Line Leak Detector. Model: VR 849490-003 ❑ 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). Dispenser ID: 01-02 Dispenser IDS 03-04 ❑ Dispenser Containment Sensor(s). Model: None ❑ Dispenser Containment Sensor(s). Model: None QQ Shear Valve(s). QQ Shear Valve(s). pQ Dispenser Containment Float(s)and Chain(s). Q9 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 06-06 Dispenser ID- 07-08 ❑ Dispenser Containment Sensor(s). Model: None ❑ Dispenser Containment Sensor(s). Model: None 09 Shear Valve(s). QQ Shear Valve(s). Q9 Dispenser Containment Float(s)and Chain(s). QQ Dispenser Containment Float(s)and Chain(s). Dispenser ID' 09-10 Dispenser ID- 11-12 ❑ Dispenser Containnment Sensor(s). Model: None ❑ Dispenser Containment Sensor(s). Model: None Q9 Shear Valve(s). QQ Shear Valve(s). Q9 Dispenser Containment Float(s)and Chani(s). Q9 Dispenser Containment Float(s)and Chain(s). If the facility contains more tanks or dispensers,copy this form.Include infmmmation 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-RonW Signature: Original on file at SSS Certification No.: 290-62-0088 License. No.: 485184 Testing Company Name: Ser. Sta. Sys. Phone No.: (408) 971-2445 Site Address: 2375 W. Grant Line @ 1-205 Date of Testing/Servicing: 06/03/03