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JUL-04-2808 12:00 Service Station Systems 488 938 8888 P.02 <br /> MonitorinjPSystern Equipment &rtification <br /> For Use By,411 Jurisdictions Within The State of California <br /> Authority Cited: Chapter 6.7, Health and Safety Code; Chapter .16, Division 3, Title 23, California Lode of Regulations <br /> This forth must be used to document testing and servicing of monitoring equipment, A e crate certification or report must be <br /> prepared for ewb-agnitoring system control panet by the:technician who performs the work. A copy of this forret must be provided <br /> to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating DIST system <br /> within 30 days of test date. <br /> A. General information <br /> Facility Name: Raley's Bidg. No.: <br /> Site Address: 4219 Morada Ln. City: Stockton, CA Zip: 96212- <br /> Facility Contact Person: Kaltlin B. Contact Phone No.: (209)956-9300 <br /> Make/Model of Monitoring System: V/R TLS-350 Date of Testing/Servicing: 615108 <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicate specific equipment inspcctedtserviced: <br /> Tank ID'01-Rego _ Tank[D: 02-Prem <br /> 0 in-Tank Gauging Probe. Mode►; VR 1147390.109 ps In-Tank Guuging Probe, Model: VR 447330-109 <br /> % Annular Space or Vault Sensor, Modcl: VR 754ae0.303 1 Annular Space or Vault Sensor. Mudel: VR 794380.303 <br /> 13 Piping Sump 1'I-ranch Sensor(s). Model: VR 794380-208 Q( Piping Sump 1 Trench Sensor{s). Mndel: VR 794380.208 <br /> fd Fill Sump Scnsor(s). Model: VR 7943®0,208 19 Fill Sump Sensor(s). Model; VR 794390.208 <br /> E3 Mechanical Line Leak Detector, Model: Nor- p Mechanical Lino Leak Detector, Model: _None <br /> QI Electronic.Line Leak Detector. Model:_ yR series 8484 3 Electronic Line Leak Detector. Model: VR series rasa <br /> El Tank Overfill 1 High-Level Sensor. Model: None ❑ Tank Overfill l high-Level Sensor, Modcl; Nona <br /> IX Other(specify equipment type and model in Scetion E on Page 2). 13 Other(specify equipment type and model in Section E on Page 2). <br /> Tank IIS' 0"ieselI Tank ID <br /> ($ In-Tank Gauging Probe, Model: VR 847320.109 CI In-Tank Gauging Probe. 4lodcl; <br /> Cl Annular Space or Vault Sensor. Model: VR 794390.303 ❑ Annular Space or Vault Sensor, Model; <br /> 3 Piping Sump 1 Trench Sensor(s). Model: Ver 794390.209 ❑ Piping Sump 1 Trench Sensor(s), Model: <br /> 12 Fill Sump Sensor(s). Model: VR 794380.208 ❑ Fill Sump Senwr(s). Mcdcl: <br /> ❑ Mechanical Line Leak Detector. Modcl; None Mechanical Line Leak Detector. Model: <br /> lg Electronic Line Leak Detector. Modcl; vR Sorsa 88484 ❑ Electronic Line leak Dctcctor, Model: <br /> l7 Tani:4verlill 1 High-Level Sensor, Model: Nona _ _ p 'Tank Ovcrfiil 1 High-Level Sensor. Model: <br /> 13 Other(specify equipment type and model in Section Eon Pagc 2), 0 Other(specify equipment type and model in Section h on Page 2). <br /> Dispenser ID,: 01-02 Dispenser YD: 00.04 <br /> C1 Dispenser Containment Sensor(s). Model: VR 794380.208 Qt Dispenser Containment Sensor(s). Madel: VR 794380.200 <br /> EX Shear Valve(s). IN Shear Valve(s).. <br /> p Dispenser Containment Float(s)and Chain(s), ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser IDT 05.06 Dispenser ID: 07-08 <br /> IS Dispenser Containment Sensor(s), Model: VR 79438a2oe_____ _ a Dispenser Containment Scnsor(s). Model: VR 79080-208 <br /> C& Shear Valve(s). 2 Shear Valve(s), <br /> ❑ Dispenser Containment Float(s)and Chain(s). p Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID- 09-10 Dispenser ID• 11-12 <br /> IX Dispenser Containment Sensor(s), Model. VR 794380.209 I2; Dispenser Containment Sensor(s). Model: VR 794380.208 <br /> M Shear Valve(y). 11 Shear Valve(s). <br /> 13 Dispenser Containment Float(s)and Chain(s). l3 Dispenser Containment Float(s)and Chain(s). <br /> •If the facility contains more tanks or dispensers,copy this form.Include information for every tank and dispenser at the facility <br /> C. Certification- I certify that the equipment identified in this document was inspected/serviced in accordance with the <br /> manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verify that this <br /> information is correct and a Piot Plan showing tilt lay0nt of monitoring equipment. For any equipment capable of generating such <br /> reports,I have also attached a copy of tile', (check all that apply): q System set-up p Alarm history report <br /> Technician Name(print). Bryan Lundien Signature: <br /> Mfg.Cert.#.: B36094 ICC# 8001468-U License,No.: 485184 <br /> Testing Company Name: Serv.Sta.Sys. Phone No.: (408)971-2445 <br /> Testing Company Address: 680 Quinn Ave.,San Jose CA 95112 Date.of Testing/Servicin;: 615103 <br />