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tib: FEB -04-2009 20:20 Service Station Systems 408 938 Beee P.03 Monitori# System equipment 'ertiiication Fo se Lay All Jurisdictions Within The State of CatyLrnia Authority Cited. Chapter 6 7, Health anti Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or repr.rt_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 roust 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 I Bldg. No.: Site Address: 1804 West 11Th. Street @ Corral Hallow City: Tracy, CA Zip: 95376 - Facility Contact Person: Make/Model of Monitoring System: VIR TLS -350 B. Inventory of Equipment Tested/Certified 1'10 k tho unnrnnrinto h- M indirufr s evilir enuinenent insnerted/serviced- Contact Phone No.: (209) 830-2950 Datc of Testing/Servicing: 12129108 Tank ID: Tank 11): E3 In - Tank Gauging Probe. Model: ❑ in -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: p Annular Space or Vault Sensor. Model: Q Piping Sunip \ -)Tench Sensor (s). Model: ❑ Piping Surnp \ Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model:_ ❑ Mechanical Line U -Ltk Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic [,inc i.eak Detector. Model: 0 Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High -Levet Scnwr. Model: Q Other ( specify equipment type and model in Section C ort Page 2). ❑ Other ( specify equipment type and model in Section E on Page 2). Tank 1% Tank ID: ❑ In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model; ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump \"french Sensor (s). Model: q Pipi)lg Sunip \ Trcnch .Sensor (s). Model' ❑ Fill Sump Sensor (s). Model: Q Fill Sump Sensor (s). Model: ❑ Mechanical Linc Lcuk Ocl.ectur. Model: ❑ Mechanical bine Lcak Detector. Model: p Electronic l.,inc Leak Detector. Model: ❑ Electronic Linc Leak rXI;tector. Model: ❑ Tank Overfill \ High -hovel Sensor. Model: ❑ Tank Overfill \ High-level Sensor. Model: ❑ Other (specify equipment type and model in Section E inn Page 2). ❑ Other (spcCify equipment type and model in Section E on Page 2). DApenser ID• 1 D' enser IA:_ 1 b Containment Sensor (s). Model: pf Dispenser Containment Sensor (s). Model: Lq' Dispenser [I ,Shear Valve (s). ❑ Shear Valve (s). Q Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (5) and Chain (5). Dispenser 1A ' I 1)' penser Containment Sensor (s). Modcl: 1 Dispenscr Containment Sensor (s). Model: Uispcn5er d Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser IDS _ _ Dispenser ID ❑ Dispenser Containmcnt .Sensor (s). Model: ❑ Dispenser Containment Sensor (s), Model: ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Contairiment Float (s) and (,huin (s). *If the facility contains more tanks or dispensers copy this form Include mtbrmatlon for cvcry tang ana ulspen.Ser at Inc ,x.-.]I«y 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 Flat Plain showing the layout of monitoring equipment. For any equipment capable of generating such reports, i have also attached a copy of the; ( check aural apply); '❑ System set-up ❑ Alarm history report Technician Name (print): Dan Madrid Signature: Mfg. Cert.#.: ICC# 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: 12129/08