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FtF CENED Monitoring System Equipment CertificatlgR 4iolio For Use By All Jurisdictions Within The State of California Authority Cited.- Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulation This form must be used to document testing and servicing of monitoring equipment. A separate certification r FITMENT 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. City_ Tracy, CA zip: 95376 - Facility Contact Person: Manager Contact Phone No.:_ (209) 830-2950 Make/Model of Monitoring System: VR TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced; Date of Testing/Servicing: 6/12118 Tank ID:01-Regu Tank ID: 02 -Prem 10 In - Tank Gauging Probe. Model: VR 847390-109 11 In - Tank Gauging Probe. Model: vtt 847380-109 iia Annular Space or Vault Sensor. Model; VR 794390-460 as Annular Space or Vault Sensor. Model: VR 7943 90-06 9 ® Piping Sump 1 Trench Sensor (s). Model: VR 794380-208 ® Piping Sump \ Trench Sensor (s). Model: VR 794360-208 N Fill Sump Sensor (s). Model: VR 794380-208 da Fill Sump Sensor (s). Model: VR 794389-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: vR series 9484 1& Electronic Line Leak Detector. Model: VR 848480-001 11 Tank Overbill \ High -Level Sensor. Model: VR 790051-001 ® 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 ❑ ID: In - Tank Gauging Probe. Model: ® In - Tank Gauging Probe. Model: VR 847399-109 ® Annular Space or Vault Sensor. Model: VR 794390.480 ❑ 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 754380-20e ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: X 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 Ila Dispenser Containment Sensor (s). Model: VR 7x4380-208 ® Dispenser Containment Sensor (s). Model: VR 794380.208 as Shear Valve (s). as Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 05-06 Dispenser 1% 07-08 as Dispenser Containment Sensor (s). Model: VR 794380-208 as Dispenser Containment Sensor (s). Model: VR 794380-208 00 Shear Valve (s). as 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: VR 794380-208 as Dispenser Containment Sensor (s). Model: VR 794380-208 $1 Shear Valve (s). as Shear 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 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; (cbeckall thatapply): ® System set-up as Alarm history yreport Technician Name (print): Kris Bell Signature: Mfg. Cert.#.: 633709 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: 6/12/18