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MonitorinoSystem. Equipment -irtification 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 monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system owner/Cfg.UserName. The owner/Cfg.UserName must submit a copy of this form to the local agency regulating UST sy: within 30 days of test date. A. General Information Facility Name: Safeway 2600 Bldg.No.: Site Address: 1987 West 11Th. Street @ Corral Hallow City: Tracy, CA Zip: 95376- Facility Contact Person: Katrina Contact Phone No.: (209) 830-2950 Make/Model of Monitoring System: V/R TLS-350 Date of Testing/Servicing: 10/02/03 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:01 -Regu Tank ID: 02-Plus ❑ In-Tank Gauging Probe. Model: VR 847390-107 ❑ In-Tank Gauging Probe. Model: VR 847390-107 ❑ Annular Space or Vault Sensor. Model: None ❑ Annular Space or Vault Sensor. Model: None ❑ Piping Sump\Trench Sensor(s). Model: None ❑ Piping Sump\Trench Sensor(s). Model: None ❑ Fill Sump Sensor(s). Model: None ❑ Fill Sump Sensor(s). Model: None ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None ❑ Electronic Line Leak Detector. Model: None ❑ Electronic Line Leak Detector. Model: None ❑ Tank Overfill\High-Level Sensor. Model: None ❑ Tank Overfill\High-Level Sensor. Model: None ❑ 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: 03-Prem Tank ID• ❑ in-Tank Gauging Probe. Model: VR 847390.107 ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: None ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: None ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: None ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: None ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: None ❑ 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: 01-02 Dispenser ID: 03-04 ® Dispenser Containment Sensor(s). Model: VR 794380.208 Q9 Dispenser Containment Sensor(s). Model: VR 794380.208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05-06 Dispenser ID• 07-08 8 Dispenser Containment Sensor(s). Model: VR 794380.208 S Dispenser Containment Sensor(s). Model: VR 794380-208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 09-10 Dispenser ID: 11-12 M Dispenser Containment Sensor(s). Model: VR 794380-208 gg Dispenser Containment Sensor(s). Model: VR 794380.208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *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 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 of generating such reports,I have also attached a copy of the; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name(print): SSS-RobertR Signature: Original on file at SSS Certification No.: 552-49-3710 License.No.: 485184 Testing Company Name: Ser. Sta. Sys. Phone No.: (408) 971-2445 Site Address: 1987 West 11Th. Street @ Corral Hallow Date of Testing/Servicing: 10/02/03