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-11 RECEIVEL Monitoring System Equipment Certificatij)ft 17 2016 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 C�efruaf l�/Nktsl ENTAL This form must be used to document testing and servicing of monitoring equipment. A separate certificationC�V VIIIVIiV iVI ^ChIT 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/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 Bldg No.: Site Address: 2808 Country Club Blvd. City: Stockton,CA Zip: 95204- Facility Contact Person: Manager Contact Phone No.: (209)461-5555 Make/Model of Monitoring System: VR TLS-35OR Date of Testing/Servicing: 1119/16 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspect ed!.serviced: Tank ID: Tank IQ, ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(a). Model: ❑ Piping Sump Trench Sensor(a). Model: ❑ Fill Sump Sensor(st Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Spa"or Vault Sensor. Model. ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump Trench Sensor(a). Model: ❑ Fill Sump Sensor(s) Model. ❑ Fill Sump Senior(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model. ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 13-74 Dispenser IQ, 15-16 ® Dispenser Containment Sensor(s) Model: VR 79,13841J22 0 Dispenser Conminmem Sensor(s). Model. VR 794390322 ® Shear Valve(s). 11 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model ❑ Dispenser Containment Sensor(s) Model. ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float 0)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(a) Model 1 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Vahe(s)_ ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Ploat(s)and Chain(a). •If the facility contains more tanks or dispensers,copy this form.Include information for even tank and dispenser at the facility C.Certillcation- 1 certify that the equipment identified in this document was inspected/semiced in accordance with the manufaelurer'sguidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verify that this Information is cornet and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy or the: (rhechailthatapp/v): ❑ Systemset-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.: (408) 971-2445 Testing Company Address: 680 Quinn Ave.,San Jose, CA 95112 Date of Test ing/Seryicing: 1119116