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OCT-01-2004 18:36 SFDVICE STATION SYSTEM 408 971 0135 P.04 Monitorh . System Equipment -.,ertification .Por Use By All Jurisdictions Within The State of Califonda Authority Cited: Chapter 67,Health and Safety Code; Chapter 16,Division 3, Title 23, California Code ofRegulations This form must be used to document testing and servicing of monitoring equipment.A scparate certification or report must be prepared for each monitoring system controlpanel 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 systcrn 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: V/R TLS-350 Date of Testing/Servicing: 912104 B. Inventory of Equipment Tested/Certified Check the appropriate bo.us to indicate specific equipment Impected/serviced. Tank MI. Tank ID: p In,Tank Gauging Probe. Model: ? 0 In-Tank Gauging Probe. Model: ? Cl Annular Space or vault Sensor. Model: 7 0 Annular Space or vault Sensor. Model: ? U Piping Sump 1 Trench Sensor(s). Model; 7 ❑ Piping Sump 1 Trench Sensor(s). Model: 7 O Fill Sump Sensor(s). Model: ? a Fill Sump Sensor(s). Model: 7 _ Q Mechanical Line Leak Dcteotor. Model: ? Mechanical Line Leak Detector. Model: ? p F lcctronic Linc Leak Detector. Model: ? Ficetmnic Linc Leak Detector. Model: ? 0 Tank Overfill l High•Lmml Sensor_ Model: Tank Overfill\High-Level Sensor. Model: ? 0 Other(specify equipment type and model in Section E on Page 2)- ❑ Other(specify equipment type and model in Section F,on Page 2). Tank ID: 'rank ID: 0 In-Tank Gauging Probe. c: ? © in•Tatilc Gauging Probe. Model: 7 ❑ Annular Space or Vault Sensor. Model: 7 _ ❑ Annular Space or Vault Sensor. Model: 7 p Piping Sump\Trench Sensor(s). Model: 7 _ 0 Piping Sump 1 Trench Sensor(s). Model: ? 0 Fill Sump Sensor(s). Model: 7 0 Fill Sump Sensor(s). Model: ? 0 Mechanical Linc Leak Detector, Model: 7 l] Mechanical Lina Lcak Detector. Model: ? 0 Electronic Una leak Detector. Model: ? t7 F,lectronic Linc Leak Detector. Model: ? ❑ Tank Overfill\High-Level Sensor. Model: 7 0 Tank Overfill\High-neve!Sensor. Model: 7 ❑ Other(specify equipment type and model in Section F on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 13-14 Dispenser ID: 15-16 DispenserContainmentSensor(s). Model: vtt7s4seoaos Dispenser Containment Sensor s). Model: VR 7$Q130-20 Shear Valve(s). Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). (7 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 17-18 Dispenser ID: 19-20 Dispenser Containment Sensor(9). Model:�VR 794330-20A DispenserContainhucnt Sensor OT e; VR 794330-2U Shear Valve(s). Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 17 Dispenser Containment Float(s)and Chain(s)- Dispenser ID: Dispenser TD; 0 Dispenser Containment Sensor s} model: ? ❑ Dispenser Contatntuent sensor(s). Model: ? 0 Shcar Valve(s). ❑ Shear Valva(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 OW document was iospcctcd/servieed ala accordance with the manufacturer's guldelines. Attached to this Certification Is information(e.g.manufactures'ebceklisti)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 rharappb,): © System set-up ❑ 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