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FEB-20-2006 15:12 Service Station Systems 408 938 88ee P.04/07 Monitoring System Equipment�Certifieation For Use By All Jurisdictions Within The State ofCalffornia Authority Cited. Chapter 6.7,Health and Safety Code, Chapter 16, Division 3, Title 23, California Cade of Regulations This form must be used to document testing and servicing of monitoring equipment. A 3enarate certification or report must be mepmad for each mtmitpdiip system control panel by the technician who performs the work. A copy of this form must be provided to the talk 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 Informat(on Facility Name: Safeway#1769 Bldg.No.: Site address: 2802 Country Club Blvd.IM Delano Ave City: Stockton, CA Zip: 95204- Facility Contact Person: Christie Contact Phone No.: (209)461.5555 Make/Model of Monitoring System: V/R TLS-350 Date of'resting/Servicing: 1124/06 B. Inventory of Equipment Tested/Certified Cheek the appropriate boxes to indicate specific equipment iuspected/serviced: Tank ID' Tank ID: p In-Tank Gauging Probe, Model: 7 0 In-Tank Gauging Probe, Model: 7 0 Annular Space,or Vault Sensor. Model: 7 Q Annular Space or Vault Sensor. Model: 7 0 Piping Sump\Trench Sensor(s). Model: 9 _ 0 Piping Sump\Trench Sensor(s). Model: 7 ❑ Fill Sump Sensor(s). Model: 7 _ Cl Fill Sump Sensor(s). Model; 7 Cl Mechanical Line Leak Detector. Model: 7 0 Mechanical Lina Leak Detector. Model: 7 E3 Electronic Linc Leak Dctccwc Model: 7 0 Electronic Line Leak Detector. Model: 7 0 Tank Overfill\High-Level Sensor. Model: 7 0 Tank Overfill\high-Level Sensor. Model: 7 0 Other(specify equipmetn type and model in Section E on Page 2), Q Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID• ❑ In-Tank Gauging Probe. Model: 7 p In-Tank Gauging Probe. Model: 7 q Annular Space or Vault Senior. Model: 7 O Annular Space or Vault Sensor. Model; 7 0 Piping Sump 1 Trench Sensor(s). Model 7 p Piping Sump\Trench Sensor(s). Model: 7 0 Fill Sump Sensor(a). Model: 7 p Fill SUMP SM50F(s). Model: 7 p Mechanical Line Leak Detector. Model: 7 0 Mechanical Linc Leak Detector. Model: 7 0 Electronic Line Leak Detector, Model: 7 0 Electronic Line Leak Detector. Model: 7 O an Ovartill\High-Level Sensor. Model: 7 t3 Tank Overfill l High-Level Sensor. Model: 7 0 Other(specify equipment type and model in Section E on Page 2), 0 Other(specify equipment type and model in Section E on PaRVR e 2) Dispenser ED- 18-14 Dispenser ID: 15.18 0 Dispenser Containment Sensor(s). Model: VR 794740422 tt Dispenser Containment Sensor(s). Madel: tt Shear Valve(s). Qt, Shear Volvo(s). D Dispenser Containment Flout(s)and Chain(a). O Dispenser Containment Float(s)and Chain(s). Dispenser ID• Dispenser ID: Q Dispenser Containment Sensor(s). Model: 7 0 Dispenser Containment Sensor(s). Model:0 Shear Valve(s). 0 ShearValve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser D):0 Dispenser Containment Sensor(s). Model: 7 0 Dispenser Containnran Scnsor(s). Model: C] Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). ED] Dispenser Containment Float(s)and Chain(s). elf the facility,contains mom tanks or dispensers,copy this farm.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 orgencrefing such reports,I have also attached a copy of the; (check alt that appop): 0 System act-up 0 Alarm history report Technician Name(print): SSS-MattM Signature: Certification No.: License,No.: 485184 Testing Company Name: Ser.Sta.Sys. Phonc No.: (408)971-2445 Site Address: 2802 Country Club Blvd.go Delano Ave — Date of Testing/Servicing: 1/24/06