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FEE -04-2009 20:20 Service Station Systems 408 938 8888 P.02 Monitoriz - System equipment 'ertitication Fur cJse By All Jurisdictions Within The State of Cal yurnia Authority Cited. Chapter 6.7, Health and Safety Code: Chupter 16, Divisiun 3, Title 23, CalVbr Iiia Code of Regulations This form must be used to document testing and servicing ei'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: 1804 West 11Th. Street @ Corral Hallow City: Tracy, CA Zip: 95376 - Facility Contact Person: P \A,-, Contact Phonc No_: 209 830-2950 Make/Model of Monitoring System: V/R TLS -360 Date of Testing/Servicing: " &`' _ B. Inventory of ]Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inSpectedlserviced: Tank I%F=. , _ Tank TD;, jjA 5 In - Tank Gauging Probe, Annular Space or Vault Sensor. Model: ;Q i Modcl IR In - Tank Gauging Probc, O Annular Space or Vault Sensor. Model: Modcl: o Piping Sump \ Trench Sensor (s). Model: O g Piping Sump \'french Sensor (s). Model Ib Fill Sump Sensor (s). Model: 2-o tj t} Fill Sump Sensor (s). Model: p Mechanical Line Leak Dctcctor, Model, ❑ Mechanical Linc Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Dctcctor. Model: ❑ Tank Overfill\ High -Level Sensor. Model: ❑ Tank Overfill \ f Iigh-Level Sensor. ModcC ❑ Ocher ( spcelfy equipment type and model in Section C on Page 2). ❑ Other ( specify equipment type and model in Section E on Pagc 2). Tank 1% Tank W; 'V In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Model: 1 Annular Space or Vault Sensor. Model: ir0 ❑ Annular Space or Vault Scnsor. Model: Ir Piping Sump \ Trench Sensor (s). Model: p Piping Sump \ Trench Scnsor (s), Model: 1p Fill Sump Sensor (s). Model: ❑ rill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Dctcctor, Model: ❑ Electronic Line Leak Detector. Modcl: q Clectronic Line Leak Detector. Model: ❑ 'funk Overfill \ High -Level Sensor. Modcl, ❑ Tank Overfill \ l-ligll-Level Scnsor. Model: ❑ Other (specify equipment type and model in Section E on Pagc 2). ❑ Other (spccifv equipment type and model in Scction Eon Page 2). Dispenser I% x— Dispenser 1D' re rp lk Dispenser Containment Sensor W. Model: so Dispenser Containmcnt Scnsor (s), Model: ❑ Shear Valve (s). O Shcar Valve (s). E3 Dispenser Containment Float (s) and Chain (s). p Dispenser Containmcnt float (s) and Chain (s). Dispenser ID' Dispenser IT) W Dispenser Containmcnt Sensor (s). Model: _ fo Duponser Containment Sensor (s). Model: ❑ Shear Valve (s). ❑ Shcar Valve (s). ❑ Dispenser Containment Float (s) and Chain (s)- ❑ Dispcnser Containment Pioat (s) and Chain (s)_ DispenserID- —!p Dispenser ID- '' L lI Dispenser Containment Sensor (s). Model: sh Dlspcllscr Containment Sensor (s). Model: 45 t5 Shear Valve (s). ❑ Shcal Valve (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 term_ Include information for ,very tank and dispenser at the facility C. Certification -I certify that the equipmeut identified in this document was inspected/serviced in Accordance wills the manufacturer's guidelines. Attached to this C'ertiticatian is information (e.g. manufactures' checklists ) necessary to verify that this information is correct and a Plot Plain showing the layout of monitoring equipment, For any equipment capable of generating such reports, f have also attached a copy of the; ( check all thal apply): $ Systein set -tap alar ais ry report Technician Name (print): Dan Madrid Signature: Mfg. Cert_ #.: ��' 13'� ICC# h 2j J^ '� License. No : 184 Testing Company Name: Serv. Sta. Sys. Phone No.: (408) 971-2445 Testino Company Address: 680 Quinn Ave., San Jose CA 95112 Date of Testing/Servicing:_ \ la O