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":)h- 71VD Monitoring System Equipment Certification'-' For Use By All Jurisdictions Within The State of California JUL- 2 ®2 1 7 Authority Cited: Chapter 6.7, Health and 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 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: 1987 W. 11th St. Facility Contact Person: Manager Make/Model of Monitoring System: VR TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seryiced: City: Tracy, CA Zip: 95376 - Contact Phone No.: (209) 830-2950 Date of Testing/Servicing: 6/20/17 Tank ID• 01-Regu _ Tank IDL12-Prem ® In - Tank Gauging Probe. Model: VR 847 3 90-1 09 ® In - Tank Gauging Probe, Model: VR 847390-109 ® Annular Space or Vault Sensor. Model: VR 794380.480 ® Annular Space or Vault Sensor. Model: VR 794390460 ® Piping Sump \ Trench Sensor (s). Model: VR 794380-208 ® Piping Sump \ Trench Sensor (s). Model: VR 784380-208 ® Fill Sump Sensor (s). Model: VR 794380-208 01 Fill Sump Sensor (s). Model: VR 784380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR Series 8484 ® Electronic Line Leak Detector. Model. VR Series 8484 ® Tank Overfill \ High -Level Sensor. Model: VR 790091-001 ® Tank Overfill \ High -Level Sensor, Model: VR 790091-001 ❑ 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 -Diesel Tank IQ: ® In - Tank Gauging Probe. Model: VR 847390-10e ❑ In - Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 794390460 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump \ Trench Sensor (s). Model: VR 794380-208 ❑ Piping Sump \ Trench Sensor (s). Model: ® Fill Sump Sensor (s). Model: VR 794380-208 p Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR series 8484 ❑ Electronic Line Leak Detector. Model. ® Tank Overfill \ High -Level Sensor. Model: VR 790091-001 ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ Other ( specify equipment type and model in Section E on Page 2). Dispenser ID: 01 02 Dispenser ID_ 03-04 11 Dispenser Containment Sensor (S). Model: VR 794390.206 ® Dispenser Containment Sensor (s). Model: VR 794380-208 ® Shear Valve (s). 0 Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser IR., 05-06 Dispenser ID: 07-08 3 Dispenser Containment Sensor (s). Model: VR 794380-208 ® Dispenser Containment Sensor (s). Model: VR 794380 -los ® Shear Valve (s). ® Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID• 09-10 _ Dispenser ID• 11-12 ® Dispenser Containment Sensor (s). Model: yR 794380-208 ® Dispenser Containment Sensor (s). Model: VR 794380-208 ® Shear Valve (s). ® Shear Valve (s). ❑ Dispcnser 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 a copy of the, (check all that apply): ® System set-up ® Alarm 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 Date of Testing/Servicing: 6/20/17