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SEP -24-2007 13:56 Service Station Systems 408 938 8888 P.03 Monitori System EquipmentWertification For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, DTVISIOn 3, Title 23, California rode of Regzllution This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be pre aared_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= 1804 West 11Th. Street (& Corral Hallow Facility Contact Person: Bill City: Tracy, CA Zip: 95376 - Contact Phone No.: (209) 830-2950 Make/Model of Monitoring System: V/R TLS -350 Date of Testing/Servicing: 8/2/07 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank I% Tank to, ❑ In - Tank ('aging Probe. Model; ❑ In - Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor, Model: ❑ Annular Space or Vault Sensor. Model: O Piping Sump \ Trench Sensor (s), Model: ❑ Piping Sump \'trench Sensor (s). Model: CJ Fill Sump Sensor (s). Model: Cl Fill Sump Sensor (s), Model: ❑ Mechanical Line Leak Detector Model Q Mechanical t.inc Leak Detector. Model: ❑ Electronic Line Leak Detector, Model- ❑ Electronic bine Leak Detector. Model: Q Tank Overfill \ High -Level Sensor. Model: ❑ 'tank Overfill \ High -Level Sensor. ivlodel; ❑ 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 IDS Tank ID• El In - Tank Gauging Probe, Model: ❑ In -Tank Gauging Probe. Model. [3 Annular Spacc or Vault Sensor. Model: ❑ Annular Space or Vault Sensor, Model: [3 Piping Sump \ Trench Sensor (s). Mcdcl: Cl Piping Sump \ Trench Sensor (s). Model: [3 fill Sump Sensor (s). Modcl; ❑ Fill Sump Sensor (s), Model: ❑ Mechanical Line Leak Detector, Model (a Mechanical Line Leak Detector. Model. ❑ Electronic Linc Leak Dctcctor. Model: ❑ P.lcctronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: E3 'tank Overfill \ Iligh-Level Sensor. Model: ❑ Other ( specify equipment type and model in Section E on Page 2). [1 Other ( specify equipment type and model in Section 1', on Page 2). Dispenser ID: 18-14 Dispenser IDL15-16 M Dispenser Containment Sensor (s). Model: VR 7aaaso-los _ a Dispenser Containment Sensor (s), Model: VR 794380.0813 Shear Valve (s). JA Sheaf Valve (s)_ ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser (:ontainntcnt Float (s) and Chain (s). Dispenser ID: 17-18 p Dispenser 1D: IX Dispenser Containment Scnsor (s). Model: VR 79438e -2e2 13 Dispenser Containment Sensor (s). Modcl; Qj Shear Valve (s). (3 Shear Valve W. ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (a) and Chain (s). Dispenser TD:_ Dispenser ID: ❑ Dispenser Containment Sensor (s). Model' ❑ Dispenser Containment Sensor (s), Model: ❑ Shear Valve (s). ❑ Shear Valve (s). El 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 tills information is correct and a Plot Platt showing the layout of monitoring equipment. For any equipment capable of generating such reports, [ have also attached a copy of the. ( check all that apply), (K System set-up I8 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/Servicino: 8/2107