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Monitoring System Equipment k_.ert cation ' For Use By All Jurisdictions Within The State of California J U N Authority Cited.- Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code o�f Rej,uIations This form must be used to document testis and servicing of monitoring '"`r0- 'l` g g g equipment. A separate certification or report mtiS`t be prepared for each monitoring system control panel by the technician who performs the work. A copy of this -form must bq_-p;ovided 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: 1804 West 11Th. Street @ Corral Hallow City: Tracy, CA Zip: 95376- FaciIity Contact Person: Manager Contact Phone No.: (209) 830-2950 Make/Model of Monitoring System: V/R TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 813/09 Tank ID01 Regu Tank ID: 02 -Plus (3 In - Tank Gauging Probe. Model: VR 847-109 l2j In -Tank Gauging Probe. Model: VR 847990-109 13 Annular Space or Vault Sensor. Model: VR 794390-420 0 Annular Space or Vault Sensor. Model: wt 794390-420 QS Piping Sump \ Trench Sensor (s). Model: vR 7943m208 13 Piping Sump \ Trench Sensor (s). Model: VR 794380-208 QI Fill Sump Sensor (s). Model: VR 794380-205 IN Fill Sump Sensor (s). Model: VR 794=-208 ❑ Mechanical Line Leak Detector. Model: None Q Mechanical Line Leak Detector. Model: None Qj Electronic Line Leak Detector. Model: VR Series 8484 13 Electronic Line Leak Detector. Model: VR series 8484 ❑ Tank Overfill \ High -Level Sensor. Model: None ❑ Tank Overfill \ High -Level Sensor- Model: None ❑ 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 -Prem Tank ID: CK In - Tank Gauging Probe. Model: VR 847390-109 ❑ In - Tank Gauging Probe. Model: I$ Annular Space or Vault Sensor. Model: VR 794390.420 ❑ Annular Space or Vault Sensor. Model: Ig Piping Sump \ Trench Sensor (s). Model: VR 794380-208 ❑ Piping Sump \ Trench Sensor (s). Model: Ig Fill Sump Sensor (s). Model: VR 794380-2011 ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector, Model: None ❑ Mechanical Line Leak Detector. Model: !g Electronic Line Leak Detector. Model: VR series 8484 ❑ Electronic Line Leak Detector. Model: i ❑ Tank Overfill 1 High -Level Sensor. Model: None ❑ Tank Overfill \ Higb-Level Sensor. Model: ❑ 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: 03-04 C1 Dispenser Containment Sensor (s). Model: VR 794380-20e 1N Dispenser Containment Sensor (s). Model: VR 794380-208 (d Shear Valve (s)- IN Shear Valve (s). 1] Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 0"6 1 Dispenser ID, 07-08 (3 Dispenser Containment Sensor (s)- Model: VR 794380-208 pj Dispenser Containment Sensor (s). Model: VR 794380-208 I'd Shear Valve (s). QI Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Cham (s). ' Dispenser ID: 09-10 Dispenser ID: 11-12 fel Dispenser Containment Sensor (s). Model: VR 794380-208 13 Dispenser Containment Sensor (s). Model: VR 794380-208 (3 Shear Valve (s). 19 Shear Valve (s). i ❑ 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 this document was inspected/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 it copy of the; ( cheek all that apply): ❑ System set-up 0 Alarm history report Technician Name (print): Bryan Lundien Signature: Mfg. Cert,4.: 836094 ICC# 8001468- U License. No.: 485184 Testing Company Name: Serv. Sta. Sys. Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose CA 95112 Date of Testing/Servicing: 813109