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JUL-02-2010 16:Z7 Service Station Systems 408 938 5888 P.04 Monitorin#System Equipment _ ?rtification 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 forth must be used to document testing and servicing of monitoring equipment. A separate certification or report 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 Bldg. No.: Site Address: 1987 West 11Th. Street City: Tracy, CA I Zip: 95376 - Facility Contact Person: Mana Make/Model of Monitoring System: V/R TLS -350 B. Inventory of Equipment Tested/Certified Check the anoronriate boxes to indicate specific eaainment insnected/serviced: Contact Phone No.: (209) 830.2950 Date of Testing Servicing: 612110 Tank TD,; Tank ID: ❑ In -Tank Gauping Probe. Model: ❑ in - Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump \ Trcnch SOOSOr (s). iodel: ❑ Piping Sump VI rench Sensor (s). Model: C] Fill Sump Sensor (5). Model: ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: p Mechanical Line Leak Detector, Model: ❑ (Icetronic Line Leak Detector. Model: ❑ Electronic Linc Leak Detector. Model: C1 Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ liigh-Level Sensor. Model: ❑ 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 Tank 10v ❑ In - Tank Cauging Probe, Model: ❑ In - Tank Gauging Probe. Model: ❑ Annular Spacc or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump \ Trcnch Sensor (s). Model- ❑ Pipind Sump 1 Trench Sensor (s), Model: ❑ Fill Sump Sensor (s). Model, ❑ Fill Sump Sensor (s). Model. ❑ Mechanical Linc t,cak Detector. Model: ❑ Mcchanicat Line Leak Detector. Model; ❑ Electronic Linc Leak Detector, Model: ❑ Electronic line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor, Model: ❑ Tank Overfill \ High -Level Sensor. Model, ❑ Othcr ( specify equipment type and model in Section [ on Page 2). ❑ Other ( specify equipment type and model in Section E on Page 2). Dispenser 1D: 13-14 Dispenser lD: 15-1 t3 M Dispenser Containment Sensor (s). Model, VR 784390.208 13 Dispenser Containment Sensor (s), Model VR 7843&0_ (21 Shcar Valvc (5). (1 Shear Valve (s). p Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containmcnt Plout (s) and Chain (s). Dispenser 1D: 17'18 Dispenser ID: 19-20 _ - % Dispcnscr Containment Sensor (s). Model: VR 794380.208 IN Dispenser Containment Sensor (s), Model; VR 794380-208 Q( Shear Valve (s), 13 Shear Valve (5)- p Dispenser Containmcnt Float (s) and Chain (s). ❑ Dispcnscr Containment Float (s) and Chain (s). Dispenser TD: _____ Dispenser LD: — [l Dispenser Containment Sensor (s), Model: ❑ Dispenser Containmcnt Sensor (s). Model: ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispcnscr Containment Float (s) and Chain (s) - *If the facility contains more tanks or di5pcnsers, 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 (c.g. manufactures' checklists ) necessary to verify that this information is correct and a Plot Plan showing the lavout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the; ( check all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): Bryan Lundien Signature: Mfg. Cert.#.: B36094 TCC# 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: 612/10