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OCT-011-2004 18:35 SEPUICE STATION SYSTEM 408 971 0135 P.02 Monitori�.� System Equipment -.ertification 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 us(A to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring stem control panel by the technician who performs The work.A copy of this form must be provide([ to the tank System owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systen within 30 days of test date. A. General.Information Facility Name:Safeway 2600 Bldg.No.: Site Address: 1804 West 11Th. Street @ Corral Hallow City: Tracy, CA Zip: 95376- Facility Contact Person: +(-1 in 0 , . -•� Contact Picone No.: (209) 830-2950 Make/Model of Monitoring System: ? -72-5 Date of Testing/Servicing:,/29rW4- B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific e(ptipmcnt inspceted/serviced: Tank ID:01• seu Tank ID: 02-Plus In-Tank Gauging Probe, Model: VR A473%-107 In-Tank Gauging Probe. Model: VR 847390-107 Annular Space or Vault Sensor. Modci: Non. e� Annular Space or Vault Sensor. Model: NonaaJ - Piping Sump\'bench Sensor(s). Model:_N_on_e%/k 22 fl'o-71J� Piping Sump\Trench Sensor(s). Model: None y �j- h Pill Sump Sensor(s), Model: None -,;Nil3b-o--20Ji( Fill Sump sensor(s). Model: Non*Vk-t'(y3B'_O 0 Mechanical Line Leak Detector, Model: None 0 Mechanical Line Leak Detector. Model: None Electronic Line Lcak Detector. Model: None ;71-L b fil-Electronic Line Leak Detector. Model: Non- e,p Q Tank Overfill\High-Level Sensor. Model: None Tank Overfill\IIigh-Level Sensor. Model: None El Other(specify equipment type and model in Section Eon Page 2). Cl Other(specify equipment type and model in Section E on Page 2). Tank ID:03-Prom Tank ID; In-Tank Gauging Probe. Modeli VR 647390.107 0 In-Tank Gauging Probe. Model: 7 Annular Space or Vault Sensor. Model: None l7 Annular Space or Vault Sensor. Model: 7 Piping Sump\Trench Sensor(s), Model: Nonet/ �`iY3y�7 ��' Piping Sump\Tncnch Sensor(s), Model: 7 Fill Sump Sensor(s), Model; Noney/p2-yy3_IV -2 © Fill Sutnp Sensor(S). Model: 7 C) Mechanical Line Leak Detector. Modcl: No.. 0 Mechanical Line Leak Detector. Model: 7 �f Electronic Line Leak Detector. Model: None 0 Electronic Line Leak Detector. Model: 7 0 Tank Overfill\High-Level Scnsor. Model: None p Tank Overfill\High-Level Sensor. Model: 7 0 Other(specify equipment type and model in Section E on Page 2). l7 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 spenser Containment Scrnsor(s). Model: VR 794;80-208 Shear Valve(s). K Shear Valve(s)- 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05-0e Dispenser ID: 07-08 Dispenser Containment Sensor(S). Model: VR 794380-208 0 Dispenser Containment Sensor(s)- Model: VR 794380.208 Shear Valve(s). 0 Shear Valve(s}. 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID; d9-10 Dispenser ID: 11-12 Dispenser Containment Scnsor(s). Model: VR 794380-206 A Dispenser Containment Sensor(s). Model: VR 794280-209 tt Shear Valve(s), 01 Shcar Vnlvc W. Cj Dispenser Containment Float(s)and Chain(s). a Dispenser Containment Float(s)and Chain(s). '"If tlic facility contains more Links or dispensers,copy this form.Include information for every tante and dispenser at the facility C. Certification- I certify that the egWpment identified in this document was impected/serviced in accordance with the manufacturer's guldelines. Attached to this Certification k information(e.g.manufactures'checklists)necessary to verify that thiq information is correct and a Plot Plan showing the layout of tuouitoring equipment. For auy equipment capable of generating such repartq,i have abo attached a copy of the; (check all d;atapply): 0 system set-up 0 Alarm bktory report 'Technician Name(print): Signature: Certification No.: `\L License.No.' 85184 Testing Company Name:Ser, Sta. Sys, Phone No.: (408)971-2445 Site Address: 1804 West 11Th. Street @ Corral Hallow Date of Testing/Servicing: 812