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OCT-01-2004 18:36 SERUICE STPTICH SYSTEr1 408 971 0135 P.03 Monitorirq System Equipment Sertification For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 67, 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-,cc parate c�ific.ation or rt port 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/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 2600 Bldg.No,: Site Address: 1804 West 11Th. Street @ Corral hallow City: Tracy, CA Zip; 95376- Facility Contact Person: Catrina Contact Phone No.: (209)830.2950 Make/Model of Monitoring System: WR TLS-350 Date of Testing/Servicing: 912104 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to 4tulicate specific equipment inspeeted/serviced: Tank ID:01-Regu Tank ID;02-Plus 0 In-Tank Gauging Probe. Model: VR 847380.107 p In-'rank Gauging Pmhe. Model: VR 847290.107 6 Annular Space or Vault Sensor. Model: VR 794390-420 Annular Space or Vault Sensor. Model: VR 794890-420 8 Piping Sump\Trench Scnsor(s). Modcl: VR 794360408 Piping Swnp\Trench Sansor(s). M6dcl: VR 794220.208 � 6 Fill Sutnp Sensor(s). Model: VR 794339-203 Fill Sump Sensor(s). Model: VR 794380,208 0 Mechanical Line Leak Detector. Model: Nano 0 Mechanical Line Leak Detector. Model: Non* Electronic Line Leak Detector, Model: VR series 9484 Electronic Linc Leak Detector. Model: VR series 8484 Tank Overfill\high-Level Sensor. Model: None ❑ Tank Ovctfill\High-I cvcl Sensor. Model: None 0 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. rem TankID: 0 In-Tank Gauging Probe. MT8of VR 847380107 0 In-Tank auging Probe, Model' ? Annular Space or Vault Sensor. Model; VR 794390.420 0 Annular Space or Vault Sensor. ModcL• 7 Piping Sump\Trench Sensor(s), Model: VR 794389408 p Piping Sump\Trench Sensor(s). Model: ? IN Fill Sump Sensor(s), Model: VR 794380-203 0 Fill Stump Sensor(s), Model: 7 0 Mechanical Line Leak Detector. Model: None 0 Mechanical Litre Leak Detector. Model: 7 Electronic Line Leak Detector, Model: VR series 8484 0 Eleclmnic Line Leak Detector. Model: ? ! 0 Tank Overfill\High-Level Sensor. Model: None I7 'Tank Overfill\High-Level Sensor. Model: 7 0 Other(specify equipment type and model in Section E on Page 2).. Q Other(specify equipment type and model in Section E on Page 2). Dispenser ID.. 01-02 Dispenser ID: 0344 Ig Dispenser Containment Sensor s). Mode: VR 794380.208 6 Dispenser Containment Sensor(s), Model: VR 794380-208 8 Shear Valve($} 8 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 06.06 Dispenser ID: 07-08 �§ Dispenser ContainmentSensor(s). Model: VR 794389-208 �§ Dispenser'CoiltaintPcniScttsor(s). Model: VR 794380.208 Shear Valve(s). Shcar Valve(s). C] Dispenser Containment Pleat(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser TD: 09-io Dispenser 1D: 11.12 �I 6 Dispenser Containment Sensor(s). el: VR 794,180,208 11 Dispenser Containment Sensor(s). Model: VR 794380-208 jj Shear Valve(s). 6 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). © Dispenser Containment Float(s)and Chain(s). i "If tic facility contains mote tanks or dispcstsers,copy this fonu.Include information for every tank and dispenser at the facility C. Certification- I certify that the equipment identitkd In tltit document was inspected/serviced in accordance with the manufacturer's guidebacs. Attached to this Ccrtirrcatwn 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): 0 System set-up 0 Alarm history report Technician Name(print):SSS-TimR Signature: Certification No.:006.05.0456 License,No.; 485184 Testing Company Name:Ser. Sta. Sys. Phone No.: (408)971-2445 Site Address: 1804 West 11Th. Street @ Corral Hallow Date of Testing/Servicing: 912104