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M onitor ing System Equipment Certificatior�L z For Use By All Jurisdictions VW thin The State of California 2015 Authority Cited: Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code of rensrY Y} ywl-� Thisform must be used to document testing and servicing of monitoring equipment. A sawatecertification or report must pre.mod for each moniton nsystem 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 wiIN n 30 days of test date. A. General Information Facility Name: Safeway Bldg. No.: SiteAddress 1987 W. 11th St. City: Tracy, CA Zip: 95376 - Facility Contact Person: Manager Contact Phone No.: (209) 830-2950 Make'Model of Monitoring System: VR TLS -350 Dateof Testing/Servicing: 6/21/16 B. I nventory of Equipment Tested/Certified Check theav rooriatebco(estoindicatesmaficequipmeMinspected/serviced: Tank I Q- 01-Regu____ Tank I D• 02 -Prem ® I n - Tank Gauging Probe. Model: 90 VR 8473-108 ® In - Tank Ga.rgi ng Robe. Model: VR 947390.108 ® Annul ar Space or Vault Saw. Mode: VR 794390480 ® Amul a Space or V ail t Sensor. Model: VR 794390480 ® Piping Stamp 1 Trench Sensor (s). Model: VR 794380-208 ® Rping Sump \ Trench Sensor (s) Mode/: VR 794380208 ® FiII Sump Sensor (s). Model: VR 794380-208 ❑ F It Sump Sensor (s). M ode: VR 794380208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Mode: ® Electrorrc Line Leak Detector. Model: VR Series 8484 ® Electronic Line Leak Detedor. Model: VR Series 8484 ® Tank Overfill \ High -Level Sensor. Model: VR 790091-001 ® Tank Overfi 11 \ Higtt-Leve Sensor. Mode: VR 790091-001 ❑ Other ( specify equipment type ail mode in Section E on Page 2). ❑ Other ( specify equipment type aril model in Section E on Page 2)_ Tank IQ E 03 -Diesel Tank IQ: ® In - Tank Ga-igi ng Probe. M ode : VR 847390.109 ❑ 1 n - Talk Gaugi ng Probe M odel : ® Amnia Space or Vault Sensor. Model: VR 794390-080 ❑ Annular Space or Vault Sensor. Model: all Piping Sump \ Trench Sensor (s). Model: VR 794390-208 ❑ Piping Sump \ Trench Sensor (s). Model: ® RI l Sump Sensor (s). Model: vR 794380-208 ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mednanical LineLeakDetector . Model: Electronic Line Leak Detedor. Model: VR series 8484 ❑ Electronic Line Leak Detector- Model: ® Talk Overfill \ High -Level Sensor. Model. VR 790091-001 ❑ Tank Overfill \ High -Leve Sensor. Model: ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ Other ( specify equipment type and model i n Section E on Page 2). Dispenser I D: 01-02 Dispenser I D: 03-04 ® Dispenser Containment Sensor (s). Model: VR 794380-208 ® Dispenser Containment Sensor (s). Model: VR 794380-208 ® ShearValve(S). ® ShearVave(s). ❑ Dispenser Containment Float (s) and Chan (s). ❑ Disperiser Contanmant Float (s) aid Clean (s). Dispenser 1 Q4 05-0fi Dispenser I D: 07-08 N DispQrnser Containment Serisor (s). Model: VR 794380.208 ® Dispenser Containment Sensor (s). Mode: VR 794380.208 ® Shea Valve (s). ® Shea Valve (s). ❑ Dispense Contarvriernt Float (s) and Chan (s). ❑ Dispenser Contanment Float (s) and Chan (s). Dispenser I D: 09-10 DiWertaer I D' 11-12 0 Dispenser Contanment Sensor (s). Model: VR 794380,208 X Dispenser Containment Sensor (s). Mode: VR 794380.208 Z ShearVave(s). ® ShearValve(s). ❑ Disperser Containment Float (s) and Chan (s). ❑ Disperw Containment Float (s) and Chan (s). .I f the fact ity conta ns more tanks or di spense s, copy IN s form. I nd ude i nformation for every tank and J Spenser at the fad ity C. Certification - I certify that the equipment Identified in this document was inspected/serviced in accordance with the manufacturer'sguidellnea Attached to thisCertificationis information (ag manufactured checklists) necessary to verify that this information is carred and a Plot Plan showing the layout of monitoring equiprnertt. For any equipment capable of generating such reports. I have also attached a copy of the-, ( check ell that appy): ❑ System set-up ❑ Alarm history report Technician Name (print): Kris Bell Signature— Mfg. Cert.#. 833709 ICC# 5297793 -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 Dateof Testing/Servicing: 6/21/16