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Monitoring System Equipment Cert 1VE For Use By All Jurisdictions Within The State of California U� 2 Authority Cited.- Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Co e q}Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certificatien,anj;AL prepared for each monitoring system control panel by the technician who performs the work. A copy offWgffHq*Vs6Ts4FdRT to the tank system owner/operator. The owner/operator must submit a copy of this forth 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 Date of Testing/Servicing: 6/12/18 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 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 \ Trench Sensor (s). Model: ❑ Piping Sump \ Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. ModeL ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ 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). Tank ID: IL• ❑ In - Tank Gauging Probe. Model: Inank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: lar Space or Vault Sensor. Model: ❑ Piping Sump \ Trench Sensor (s). Model: Sump \ Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: mp Sensor (s). 7Line Model: ❑ Mechanical Line Leak Detector. Model: anical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: Overfill \ High -Level Sensor. Madel: ❑ Other ( specify equipment type and model in Section E on Page 2). ( specify equipment type and model in Section E on Page 2). Dispenser ID_ 13-14 Dispenser IDo 15-16 ® Dispenser Containment Sensor (s). Model: VR 794380.208 ® Dispenser Containment Sensor (s). Model: VR 794380.208 N Shear Valve (s). ® Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID nser ID, 19-20 � Dispenser Containment Sensor (s). Model:yR 794380-208 enser Containment Sensor (s). Model: VR 794380-208 ® Shear Valve (s). r Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). enser Containment Float (s) and Chain (s). Dispenser 1D: F ser ID: ❑ Dispenser Containment Sensor (s). Model: enser Containment Sensor (s). Model: ❑ Shear Valve (s). r Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). enser Containment Float (s) and Chain (s). lythe 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; (cheek all that apply). 19 System set-up ® Alarm history report Technician Name (print): Kris Bell Signature: _7-- 2��' 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 Date of Testing/Servicing: 6/12/18