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M onitoring System Equipment CertificatiML 2 0 2016 For Use By All Jurisdictions lMthin The Sate of California h-, Authority Cite: Chapter 6.7, Health and Safety Co*' Chapter 16, Division 3, Title 23, California Code of f�uia Aw- Thisform must be used to document testing and servicing of monitoring equipment. A �gWateoertification 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 regui ati ng UST system within 30 days of test date. A. General Information Facility Nagle; Safeway Bldg. No.: Site Address -1 987 W. 11th St. City: Tracy, CA Zip: 95376 - Facility Contact Person: Manager Contact Phone No.: (209) 830-2950 M ake(M odel of M onitori ng System: V R TLS -350 Date of Testi ng/Servicing: 6/21/16 B. Inventory of Equipment Tested/Certified Chock the appropriate tacestoindlcatespecific equipment inspectedlserviced: TanklD: TanklD• ❑ I n - Tank Gagi rig Prone. Model: ❑ I n - Tank Gaging Probe. Mode: ❑ Annclar Space or Vault Sensor. Model: ❑ Amina Space or Vault Sensor. Model: ❑ Rpirg Sump \ Trench Saw (s). M odel: ❑ PI0rig Sump \ Trench Sensor (s). M odel: ❑ FII Sump Sensor (s). Model. ❑ FII Sump Sensor (s). Modd: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ FJectrorucLineLeak Detector. Model: ❑ EledroncLine Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Tack Overfill 1 High -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section E on Pie 2). ❑ Other ( specify equipment type and model in Section E on Page 2). Tank ID- Tank ❑ ID: In - Tank Ganging Probe. Model: ❑ In - Tank Gauging Robe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Amrdar Space or Vailt Sensor. Model: ❑ R 0 ng Sump \ Trench Sensor (s). Model: ❑ Piping SLmp \ Trench Sensor (s). Model: ❑ FillSumpSensor (s). Model: ❑ FIIScmloSensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: ❑ FJectronicLine Leak Detector. Model: ❑ Tank Overfill \ High -Leel Sensor. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Other ( specify equi prrW type and model i n Sec ti on E on Page 2). ❑ Other ( specify equipment type and model in Section E on Page 2), Dispenser I D: 13-14 Dispenser I D: 15-16 11 D Containment Sensor (s). Model: VR 7Mssn-20e ® Dispauer Contanrnart Sensor (s). Model: vrt 7e4380•209 ® Shear Valve (s). M Shea Valve (s). ❑ Dispenser Containmert Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chan (s). Dispenser IQ.. 17-18 Di5p6n89f I D: 19-20 ® DispenserContainment Sensor (s). Model: vR 79ue0-20e Containment Sensor (s). Model: ver 744380a08 ® Shear Valve (s). ® Shea Valve (s). ❑ Dispenses Containrrrent Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chan (s). Dispenser I D: __ Dispenser I OF ❑ Dispense Containment Sensor (s). Madel: ❑ Dispense Containment Sensor (s). Model: ❑ Shear Valve (s). ❑ Shaer Valve (s). ❑ Dispenser Containment Float (s) and Chaff n (s)_ ❑ Dispense Contarment Float (s) and Chan (s). .If the facility contains more tanks or dispensers, copy thisform. Include infornuaion for every tank and dispenser at the facility C. Certification -I certify that the equipmentidentifiedInthisdoam itwasinspededlservicedinaccordancewiththe manufacturer'sguideiinas Attached to this Certification is information (ag manufactured checklists) neoessary to verify that this information is oorred and a Plot Plan shoe ingthe layout of monitoring equipmerd. For any equipment capable of generating such reports, I have also attached a copy of the; ( check alf thatappty): ❑ System set-up ❑ Alarm history report Technician Name (print): Kris Bell Signature: Mfg. Cert.#.: B33709 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: 6121/16