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JUL-02-2017 16:Z6 Service Station Systems 408 938 8888 P.03 MonitorinoSystem Equipment �rtification For Use By All ,lurisdictions Within The State of California Authority Cited: Chapter 6.7, flealth 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 ceTtifi ation or report must be prepare f r Kath monitoring systern 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: 1987 West 11Th, Street Citv: Tracy, CA Zip: 95376 - Facility Contact Person: Manager Contact Phone No.: (209) 830-2950 Make/Model of Monitoring System: V/R TLS -350 Date of Testing/Servicing: 6/2/10 B. Inventory of Equipment Tested/Certified Check the ennrnnrintr boxes to indirale eneriPr eaninment insnected/serviced: Tank TD' 01-Regu Tank ID• 02 -Prem (3 In - Tank Ganging Probe. Model: VR 847390-109 (3 in -'rank Gauging Probe. Moder VR 847390-109 Qs Annular Space or Vault Sensor, Model: VR 794390-420 Qj Annular Space or Vault Sensor, Modcl: VR 794390-420 Qj Piping Sump \ Trench Sensor W. Model: VR 794380-208 Qj Piping Sump \ Trench Sensor (s). MndeL VR 79438_0-208 Qj Fill Sump Sensor (S). Model: VR 794380-208 Qj Fill Sump Sensor (s). Model: VR 794380-208 ❑ Mechanical Linc Leak Detector. Model: ❑ Mechanical line Leak Detector, Vlodel: 0 Electronic Line Lcak Detector. Model: VR series 8484 Qj Electronic Line Leak Detector. Model: VR series 8484 ❑ Tank Overfill \ High -Level Sensor. Moder p Tank Overfill \ High -Level Sensor. Modcl; ❑ Other ( specify equipment type and model in Section E on Pagc 2). ❑ Other (.specify equipmcnt type and model in Section E on Page 2). Tank ID: 03 -Diesel Tank 1Qw lB In - Tank Gauging Probe, Model: VR 347390-109 ❑ In - Tank Gauging Probe. Model: I$ Annular Space nr Vault Sensor. Model: VR 794390-420 p Annular Space or Vault Sensor. Model: (g Piping Sump \ Trench Sensor (s). Model: -V R 794380-208 - ❑ Piping Sump \ Trench Sensor (s), Model: IX Fill Sump Sensor (s). Model: VR 794380.208 ❑ Fill Sump Scnsor (s). Modcl: ❑ Mechanical Linc Leak Detector. Model ❑ Mechanical Linc Lcak pctecnor. Moder (a Electronic Line Leak Detector, Modcl: vR sones 4434 ❑ Electronic Line Leak Detector, Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ 1 ank Overfill \ I ligh-Level Sensor. Model: ❑ Other ( specify equipment type and model in Section Eon Page 2). ❑ Other ( specify equipment type and model in Section F on Page 2). Dispenser TD: 01-02 _. Dispenser iD• 03-04 (g T)ispcnscr Containment Sensor (s), Model: VR 794380-208 Qj Dispenser Containment Sensor (s), Model: VR 794380-20e 1Z Shear Valve (s). la Shear Valve (S). p Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser TD: 05-06 Dispenser ID: 07-08 (a Dispenser Containment Sensor (s). Model: VR 794380-204 (a Dispenser Contaimncnt Sensor (s). Model: VR 794390.209 a Shear Valve (s). (1 Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser TD: 09-10 Dispenser ID- 11-12 (3 Dispenser Containment Scnsor (s). Model: VR 794180.208 1 % Dispenser Containment Sensor (s). Model: VR 794380.208 Qi Shear Valve (s). Qj Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). "If the facility contain..• more tanks or dispensers, copy this torm. Incluse tntormanon Tor every tanx anu utspenser at utc uwmty C. Certification — I certify that the equipment identified in this document was inspeeted/serviced in accordance with the manufacturer's guidelines. Attached to this Certification 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 Mai apply): ❑ System set-up ❑ Alarm history report Technician Name (print): 8 an Lundien Signature: Mfg. Cert.#.: B36094 iCC# 8001468 -UT License- No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing Servicing: 6/2/10