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SEP -24-2007 13:56 Service Station Systems 408 938 8888 P.02 Monitori - System Equipmen ertification For Use All Jurisdictions Within The State o Ca i ornia BY f Authority Cited: Chapter 6.7, Health and Safety Code; Chapter /6, 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 rrenared_for each monitoring system control panel by the teclutician 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: 1804 West 11Th. Street @ Corral Hallow City Tracy, CA Gip: 95376 - Facility Contact Person: Bill Contact Phone No.: (209) 830-2950 Make/Model of Monitoring System: V/R TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 8/2/07 Tank ID- 01-ReguTank ID• 02 -Plus ❑ In -Tank Gauging Probe, Model: None ❑ In -'Dank Gauging Probe, Model: None IN Annular Space or Vault Sensor. Model: VR 784380.420 % Annular Space or Vault Sensor. Model: VR 784990-420 Q1 Piping Sump \ Trench Sensor (s), Model: VR 784980-203 13 Piping Sump \ Trench Sensor (s). Model, . VR 784360-208 11 Fill Sump Sensor (s). Model: -. yR 784988-aoa iX Fill Sump Scnsor (s). Model: VR 794380-208 El Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None Q1 Electronic Line Leak Detector. Model: yR Sories 9484 QI Electronic Line l cak Detector, Model; VR Sorlos 8484 ❑ 'rank Overfill \ High -Level Sensor. Model: __ none ❑ Tank Overfill \ High -Level Sensor. Model: None 0 Other ( specify equipment type and model in Section F on Pagc 2). 0 Other ( specify equipment type and model in Section E on Pagc 2), Tank I% 03 -Prem Tank 1D;, ❑ In - Tank Gauging Probe. Model: None ❑ In - Tank Gauging Probe. Model: ($ Annular Space or Vault Sensor. Model: VR 794390-420 ❑ Annular Space or Vault Sensor. Model: CK Piping Sump \ Trench Sensor (s). Mcxiel: VR 794380.208 ❑ Piping Sump \ Trench Sensur (s). Model: Fill Sump Sensor (s). Model: VR 784388208 ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model; Name L7 Mechanical Line Leak I)rtcctor, Model, Electronic Line leak Detector. Model: VR Series 9484 ❑ Electronic Line Leak Detector, Model, Q Tank Overfill \ High -Level Sensor, Model: None ❑ Tank Overfill \ High-i.,evcl Sensor. Model: ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ Other ( specify cquipment type and model in Section E on Page 2). Dispenser ID: 01-02 Dispenser iD: 03-04 r$ Dispenser Containment Sensor (s). Model; VR 794380-20a Q1 Dispenser Containment Sensor (s), Model: VR 744380-208 Q1 Shear Valve (s). QS Shear Valve (s), 0 Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 05-06 Dispenser ID: 07-08 Q1 Dispenser Containment Sensor (s). Model: VR 794360-206 13 Dispenser Containment Scnsoi (s), Model; VR 794380-208 Shear Valve (s), 13 Shear Valve (s), ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 09-70 Dispenser Ill: 11-12 (3 Dispenser Containment Sensor (s). Model- yR 794889-206 1% Dispenser Containment Sensor (s). Model: VR 79x380.208 (3 Shear Valve (s). 13 Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). 'If the facility eunteins more tanks or dispensers, copy this form. fnOude information for every tank and dispenser at the facility C. Certification - I eertifv that the cquipment identified in this document was inspected/serviced in accordance with the mantifacturer's guidelines. Attached to this Certification is information (e.g. manufactures' checklists ) necessary to verity that this information is correct and a Plot Plan showing the layout or monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the; ( check all that apply): M System .set-up M Alarm history report Technician Name (print): Steve M Parmenter Signature: - Mfg. Cert.# A28780 ICC# 5311561 -UT License. No.: 485184 Testing Company Name: Serv. Sta. Sys. Phone No.: (408) 971-2445 Site Address: 1804 West 11Th. Street @ Corral Hallow Date of Testing/Servicing: 812/07