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FEB-20-2006 15:11 Service Station Systems 408 938 8888 P.02/07 Monitoring System Equipment Certification For Use ldy All J.,ndwifoms Within The State of California Alrtharlty Cited.-Chapter 6.7, Health and Safety Code,Chapter 16, Division 3, Tide 23, C•alifnrnia Code ei(Regulations This form must be used to document testing and servicing of monitoring equipment. A Sqp ate certification or report-must he pEtparod fgr each monitoricon'trol-Pqatl by the technician who performs the work.A copy of this form must be provided to the tank system owner/operator. The ownerioperator must submit a copy of this form to the local agency regulating UST System within 30 days of test date. A. General Information Facility Name:Safeway#1769 Bldg.No.: Site Address: 2802 Country Club Blvd. Delano Ave City: Stockton, CA Zip: 95204- Facility Contact Person: ),'r I, Contact Phone No,: (208)461-5555 Muke(Model of Monitoring System_VIR TLS-350 Date of Testing/Servicing: 1124106 B. Inventory ofE:quipment Tested/Certified Check the Appropriate hoses W indican•sprcific equipmepf iucpected/serviced= FgAnnalar ID' n ... •. Tank ID; Tank tgaging Nobe. Modcl: of In TankGwging Prahe. Madill Space or VaultScanar. Model'. < ` s!"' t r] Ammlar Space or Vault Sensor. Model:ing Sump\TIcalch Sensor(5). Model'. r amu I Piping Sump 1I ranch sensor(5). Model: ( e 7 SmupSensor(s). Model: I r/ r:' r ci rst dl Sump Sensor(s). Model:chanical Line Leak Detwtcr, Modal: � j� Mechanical Lira:Leak Mieclor, Model:clranic I.inc I=&Detector. Model: L .0 Lloctronic Lim Leak Detector. Model:k Overfill\High-Level Sensor. Model: /'��..i 10Tank Overfill\high-Luvel Sensor. Mafel; Dlier(specify cquipolenttype tmd model in Section 1.nn Pape 2). 0 Odicr(spccit5,equipment type and model in Section I--on Page 2), [Tankin. " 'tank ID• - In.Tank Gauging Probe. Model' D In-Tank Gauging Probe. Model: lif Annular Space or Vault Sensor. Model: c' <^-`)1C'..o O Annular Space or Vault Sch9nr. Morel: Piping Surnp\Trench Sensor W. Modal; 74V'z_q,"' ❑ piping Sump\'frenoll Senator(5). Model: y) Fill Sump Sensor(a). Model:•,17c/"�'t r�'"t- �+Z• ❑ Fill Sump Scitsor(s). Modcl: 0 Mechanical Line Leak Detectol, Model: G Mechanical Cine Leak Detector. Model: F,Icclronic Linc l.cuk Detector. Modcl: ` 0 Electtunic Line Irak Detaanr, Model: Took Overfill\High-Level SCnxal. Model:��(7C%,. /^t�h'-o X 0 Took Overfill 1 High•L evc(Sensor. Model: D OdIca(5pccify equipment tyle and model in Scotian h.oil Page 2). 0 011ier(specify equipment type a ad model in Section f.on Page 2). Dispenser ID' Dispenser ID, 7 Dispenser Cantait neat Sciuor(s). Model: - � �r ✓ ❑ispense.Contatnme i!ensor(s), Madel: � — Shcar Vsdve(s). 0 Shcar Valve W. p Dispcaser Containment Float(s)and Chain(s). 0 Float(s)and Chain(s). DispenserlD' c D,penser1D' y 1 i5petuer Containtnent'Scnsur(s). Mudd; �' ' ", �Cl Dispenser Conwinrtn.nt Sinks,(s). Model: hear Valve(5). .lta3(Valve(s), L) Dispenser Containment Flout(s)and Cham(5), ❑ Dispenser Connunmont float(s)and Chain W. DLspenser 1D' _ L. ,. id Dispenser T,wainment Sensm'(s). Model: ") 'r•i 15hear ser Cenhtillmen Sensor(5). Madel'. ESSherr Vatvc(s). �$haa�Valve(x). t>ispenser Contaimnem Flast(x)and Chain(S). ❑ Dispenser(ymrainmrnl float(s)and Chain(v). -If the facility contains marc tanks or dispcow,s.tippy thls fnrnt.hlelndc intbnnanrm fin every tank and dispenser at the facility C.Certification- I certify that the cgnipmcut idettiinf in Ibis document wax inmpectedtserviced in accordance with the mauufacmrrrs euidelinrA. Attached to this Ccrti icaion is information(e.g.niaaufmiures'checklists)necessary to verify that this information is correct and A flet Pian showing the layout ofmouin.riug equipment'- For auyegnipmeatcapabfe ofl(enciatingsuch .cports,t have also attached a copy ol'the; (vhrvk all dery apptr: 0 System lel-rap �Alornt history report Technician Name(print):SS S-M IUM Sionaturo:a Certification No.: /�l e ^(�1 (9710 License.No.: 485164 Testing,Company Name; Ser. Sta.Sys. Phone No.: (408)971-2445 Site Address: 2802 Country Club Hlvd. Delano Ave .. Date of Testing/Servicing: 1124/06