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Monitoring System Equipment Certification FEB IS 20R ) For Use By All Jurisdictions Within The State of California Authority Cited:Chapter 67,Health and Safely Code;Chapter 16, Division 3, 77t1e 23, California Code of Redl1iVMIVIA �.-- 'V /-t This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/opemtoc 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 Bldg.No.: Site Address: 2808 Country Club Blvd. City: Stockton, CA Zip: 95204. FacilityContact Person: Manager Contact Phone No.: J209)461-5556 Make/Model of Monitoring System: VR TLS-35OR Date of Testing/Servicing-: 1(20115 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:o1-Regu _ Tank ID• 02-Plus a In-Tank Gnuging Probe. Model: VR 82090-109 a In-Tank Gauging Probe. Model vR U7300-109 a AnnularSpace or Vault Sensor. Model: VR 794390,420 a Annular Space or Vault Sensor. Model'. VR 794390¢10 a Piping Sump Trench Sensor(s) Model: VR 791380-208 a Piping Sump\Trench Sensor fo Model, VR 794350,362 a Fill Sump Sensor(a). Model: VR 794280,208 a Fill Sump Sensor(s). Model: VR 79/250462 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: a Electronic Line Leak Detector. Model: VR sono au4 a Electronic Line Leak Detector, Model: VR sonar 8484 a Tank Overfill\High-Level Sensor Model: VR7900914001 a Tank Overfill\High-Levet Sensor. Model VR 790091.001 ❑ Other(specify equipment type and model In Section E on Page 2) ❑ Other(specify equipment type and model m Section F.'on fags 3). Tank 1% 03-Prem 'tank ID: a In-Tank Gauging Probe. Model: VW847390-109 ❑ In-Tank Gauging Probe. Model. a Annular Spam or Vault Sensor, Model: VR 794390-480 ❑ Annular Space or Vault Sensor. Model. a Piping Sump\Trench Sensor(s). Model: VR 794330-208 ❑ Piping Sump\Trench Sensor(8). Model. a Fill Sump Sensor(s), Model VR 794350-362 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: a Electronic Line Leak Detector. Model: VR sone.eau ❑ Electronic Line Leak Detector. Model: a Tank Overfill\High-Level Sensor. Model: VR 790391401 ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section Eon Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID• 01-02 Dispenser ID: 03-04 a Dispenser Containment Sensor(s), Model'. VR 794350-322 a Dispenser Containment Sensor(s) Model VR7W3W322 a Sham Valve(s). a Shear Valve(s). ❑ Dispenser Containment Float(a)and Chain(9). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID- 06.06 Dispenser 1D: 07.08 N Dispenser Containment Sensor Is). Model: VR 79,13 122 a Dispenser Containment Sensor is). Model: VR 794380,922 a Shear Valve(s). a Shear Valve(s), ❑ Dispenser Containment Float(s)and Chain(a). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 08-10 Dispenser ID; 11-12 a Dispense Containment Sensor W. Model: VR 794393422 a Dispenser Containment Sensor(s). Model. VR 794350422 a Shear Valves) 1 a Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Cham(.al *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 k entined in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufacture'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,1 have also attached a copy of the; (eheck all tharappll): ❑ System set-up ❑ Alarm history report Technician Name(print);Kris Bell Signature: Mfg.Cert.#.: B33709 ICC# 5297793-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (406)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose, CA 96112 Date of Testing/Servicing: 1120/15