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JUL-24-2008 16:36 Service Station Systems 408 938 8388 P.C2 MonitorirlSystem Equipment Oertification 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-Regulalioris This form must be used to document testing and servicing of monitoring equipment. A separate certification or reFrnrt trust be Prepared for each rnonitoring wstem 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 LIST systern within 30 days of test date. A. General Information Facility Name: Raley's - :Bldg.No-: Site Address: 4219 Morada Ln. @ . City: Stockton, CA Zip: 95212- Facility Contact Person: Mare Contact Picone No.: 209 956-9300 Make/Model of Monitoring System: VIR TLS-350 Date of Testing/Servicing: 7/22/08 S. Inventory of Equipment Tested/Certified Cheek(lie appropriate boxes to indicate specific equipment inspected/serviced: Tank I1).01-11egu __ Tank IA• 62-Prem 3 In-Tank Gauging Probe. Model: VR 847390-109 a In.Tank Gauging Probc. kladel: VR 547390.109 Annular Space or Vault Sensor, Mode[, VR794380-303 Annulm Spacc or Vault Sensor. Ntodcl; YR 794380-303 Q( Piping Sump 1 Trench Sensor(s). Model: VR 794380-208 Piping Sump 1 Trench Sensor(4). Modcl: VR 794380-20a 13 Fill Sump Sensor(5), Model VR 7WRO.208 13 Fill Sump Sensor(s). Model: ya 7043 -206 0 Mechanical tine Lcak Detector. IMIodCI; None echanical Line Leak I)ctcaor. Model: None a Electronic Linc Lcak Detector_ Model VR Series 8454 Qt Electronic Line Leak Dnector, Model: VR series 5484 Q Tank Ovcrfill 1 high-Level Sensor. Model: None ❑ Tank Overfill 1 High-Level Sensor. MadelL None IX Other(specify equipment Type and model in Section E on Page 2) M Othcr(specify equipment type and model in Section E on Page 2). Tank ID, 113-D1e9e1 Tankl% M In-Tank Gauging Probe. Model: MR 847390-+09 [l In-Tank Gauging Probe, Model: l$ Annular Space or Vault Scnsor. Model: MR 794380.303 ❑ Annular Space or Vault Sensor. Model: IX Piping Sump 1 Trcnch Scnsor(s). Model: MR 794080.208 p Piping Sump 1 Trcnch Sensor(s). Model: 11 Fill Sump Sensor(s). Madel: VR 794380.208 p Fill Sump Scnsor(s). Model: p Mechanical Linc Leak Detector. Modcl; No— p Mechanical Line Leak Detector. Model: (g Electronic Line Leak Detector. Modct; vR sones 5454 d Elwtronic Line Leak Detector. Model; r] Tank Overfill 1 I•Iigh-Level Scnsor, Modcl:_ry-e ❑ Tank Overfill 1 High-Level Sensor, Modcl; Qt Other(specify equipment type and model in Section F on Page,2), [7 Other(specify equipmctit type and model in Section 7-on Page 2). Dispenser YD• 01-112 Dispenser ID•03-114 ® Dispenser Containment Sensor(s), Model: VR 794380-20e p( Dispenser Containment Sensor(s). Modcl: VR 794380-208 Shear Valve(s), 13 Shear Valve(s). [ Dispenser Containment Float(s)and Chain(s), El Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05-1)6 Dispenser ID: 117.118 [I Dispcnser Containment Sensor(s). Modcl: VR 744380-208 13 Dispcnser Containment Sensor(s). Model:�WR 994390.209 CK Shear Valve(s). II Shcar Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). p Dispenser Containment Float(s)and Chain(s). Dispenser TD: 09-10 Dispenser 1Dc 11-12 IX Dispenser Cpntainmcnt Sensor(s). Model:_'+R 794389-298 19 Dispetlser Contamment Scnsor(s). Mndcl: VR794380-208 pt Shear Valve(s). 13 Shcar Valve(s). p Dispenser Containment Float(s)and Chain(s). ❑ 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 Nvas inspected/serviced in accordance with the manufacturer's guideline~. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verify that this information is eorreet and a Pint Plan showing the layout of nionitaring equipment. Fur any equipment capable of generating such reports,i have also attached a copy of the, (check all that apply): ❑ System set-up E3 Alarm history report Technician Name(print)- Steve Parmenter signature: - Mfg. Cert.#.: A28780 ICC# 5311561-UT License.No.: 485184 Testing Company Name: Serv.Sta. S s. Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose CA 95112 Date of Testing/Servicing; 7122108