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FEB-20-2006 Service Station Systems 408 938 8888 P.03/07 Monitoring System Equipment4ertification 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 monitQrina system co—n t'_>c 1 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 system within 30 days of test date. A. General Information Facility Name__Safeway#1769 Bldg.No.: Site Address: 2802 County Club Blvd.Qr Delano Ave City: Stockton, CA zip: 95204- Facility 5204Facility Contact Person: Christie Contact Phone No.: (209)481-UU Make/Model of Monitoring System: V/R TLS-50 Date of Testing/Servicing: MGM B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment i9spectedtservieed: Tank ID:01-Re9u Tank ID: 0,2-Pius p In-Tank Gauging Probe. Model: VRa473aoa09 ❑ In-Tank Gauging Pmbc. Model: ve3473e0-109 Qi Annular Space or Vault Sensor. Model: VR 71413e0-420 iq Annular Space or Vault Senior. Model: Vh7943e0420 19 Piping Sump\Trench Sensor(s). Model: VR 794390d52 19 Piping Sump 1 Trench Sensor(s). Model: VR 794360,392 a Fill Sump Sensor(s). Model: VR 794390-352 _ 19 Fill Sump Sensor(s). Model: VR 794asossz ❑ Mechanical Line Lcak Detector Model: None ❑ Mechanical Line Leak Detector. Model: Nene S Electronic Lino Leak Dctoctor, Model: VR sen..94e4 R Electronic Line Leak Detector, Model: VR Serle•8494 lb Tank Overfill 1 High-Level Sensor. Model:_ _ 9S Of Tank Overfill\Iligh-Level Sensor. Model:?Cyn 09 f—OO i ❑ Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section Eon Page 2). Tank ID 03-Frem Tank ID: El in-Tank Gauging Probe. Model: VR U7390.109 ❑ In-Tank Gauging Probe. Model: 7 W Annular Space or Vault Sensor. Model: VR 764390420 ❑ Annular Space or Vault Sensor, Model: 7 ® Piping Sump\Trench Sensor(s). Model: VR 794IB0452 ❑ Piping Sump VI Sensor(s). Model: 7 IIf Fill Sump Sensor(s). Model: VR 794390-392 ❑ Fill Sump Sensor(s). Model: 7 ❑ Mechanical Line Leak Detector. Model: None p Mechanical Line Leak Detector, Model: 7 pp Electronic Line Leak Detector. Model: Vrt3ena41r494 D Electronic Line Leak Detector. Model: 9 pil Tank Overfill\High-Level Sensor. Model:_�'t UCJ ❑ 'fink Overfill\High-Level Sensor, Model 7 E3 Other(specify equipment type and model in Section E on Page 2). p Other(specify equipment type and trwdcl in Section E on Page 2). Dispenser ID: 01'02 _ Dispenser ID- 03.04 ® Dispenser Containment Sensor(s), Model: VR 704390x22 _ pp Dispenser Containment Sensor(s). Model: VR 704360-M 6 Shcar Valve(s), py' Shear Valve(s). p Dispenser Containment Float(s)and Chain(s). p Dispenser Containment Float(s)and Chain(s). Dispenser II):—Q"6 Dispenser lb: 07-03 Qg Dispenser Containment Sensor(s). Model: VR 794390-322 pp Dispenser Containment Sensor(s). Madel: V1179439a322 29 Shear Valve(s). Cg Shear Vidve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID- 09-10 Dispenser ID: 11-12 Ug Dispenser Containment Semior(s). Model: VR 7943Bo 322 pp Dispenser Containment Sensor(s). Model- VR 794390,322 Pt Shear Valve(s). 19 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). elfihe 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 inspectediserviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary in 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 al/ghat apply): ❑ System set-up 0 Alarm history report Technician Name(print): SSS-MattM Signature: Certification No.: License.No.: 488184 Testing Company Name: Ser.Sta.Sys. Phone No.: (408)971-2445 Site Address: 2802 Country Club Blvd.@ Delano Ave Date of Testing/Servicing: 1124106