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MonitorhoSystem Equipment 41 ertifictio 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 systems within 30 days of test date. A. General Information Facility Name: Shell 136187 Site Address: 2375 W. Grant Line (� 1-205 Facility Contact Person: Shauna Bldg. No.: City: Tracy, CA Zip: 95376 Contact Phone No.: (209) 836-8908 Make/Model of Monitoring System: V/R Simplicity Date of Testing/Servicing: 05/08/02 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 01 - Regu Tank ID• 02 -Plus K In - Tank Gauging Probe. Model: VR 847399.107 IN hi - Tank Gauging Probe. Model:VR 847390.107 N Annular Space or Vault Sensor. Model: VR 794380-301 N Annular Space or Vault Sensor. Model: VR 794380.301 N Piping Sump \ Trench Sensor (s). Model: VR 794380.352 0 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 RD Electronic Line Leak Detector. Model: VR 331198.001 Ig Electronic Line Leak Detector. Model: VR 331198-001 ❑ Tank Overfill \ High -Level Sensor. Model: None ❑ Tank Overfill \ High -Level Sensor. Model: None 29 Other ( specify equipment type and model in Section E on Page 2). 19 Other ( specify equipment type and model in Section E on Page 2). Tank ID• 03 - Prem Tank ID• 04 -Diesel IM In - Tank Gauging Probe. Model: VR 847390.107 K In - Tank Gauging Probe. Model: VR 847390-107 Annular Space or Vault Sensor. Model: VR 794380.301 Ig Annular Space or Vault Sensor. Model: VR 794380-301 Piping Sump \ Trench Sensor (s). Model: VR 794380.352 09 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 331198.001 Electronic Line Leak Detector. Model: VR 849490.003 ❑ Tank Overfill \ High -Level Sensor. Model: None ❑ Tank Overfill \ High -Level Sensor. Model: None 99 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 I Dispenser ID: 03-04 ❑ Dispenser Containment Sensor (s). Model: None ❑ Dispenser Containment Sensor (s). Model: None I8 Shear Valve (s). 09 Shear Valve (s). lil Dispenser Containment Float (s) and Chain (s). Ig Dispenser Containment Float (s) and Chain (s). Dispenser ID• 05-06 r ID: 07-08 ❑ Dispenser Containment Sensor (s). Model: None Containment Sensor (s). Model: None 99 Shear Valve (s). EDispenser alve (s). lig Dispenser Containment Float (s) and Chain (s). er Containment Float (s) and Chain (s). Dispenser ID: 09-10 Dispenser ID: 11-12 ❑ Dispenser Containment Sensor (s). Model: None ❑ Dispenser Containment Sensor (s). Model: None 19 Shear Valve (s). 99 Shear Valve (s). 09 Dispenser Containment Float (s) and Chain (s). Rg 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): SSS4osh Signature: Original on file at SSS Certification No.: 552-61-6176 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: 05/08/02