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s r P • '� VED Monitoring System Equipment Certifcatio P'or Use By gill Jurisdictions Within The State of C'a/ifornia D 7(�1 AuthorityCited:Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, California Code of Regi ildYi�fitY 4 This form must be used to document testing and servicing of monitoring equipment, A separate cei iification or report inust be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form inust be prow LTH 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: Will Contact Phone No.: (209)830-2950 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 11/13/14 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Inspectetllserviced: Tank ID:01-Regu Tank ID: 02-Prem ® In-Tank Gauging Probe. Model VR 847390.109 ® In-Tank Gauging Probe. Model: VR 947380.109 ❑ Annular Space or Vault Sensor. Model: VR 794390460 ❑ Annular Space or Vault Sensor. Model: VR 794390460 ❑ Piping Sump\Trench Sensor(s). Model: VR 794380.208 ❑ Piping Sump\Trench Sensor(s). Model: VR 794380208 ❑ Fill Sump Sensor(s). Model: VR 734380-208 ❑ Fill Sump Sensor(s), Model: VR 794380208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model ❑ Electronic Line teak Detector. Model: VR series 8484 ❑ Electronic Line Leak Detector. Model: VR series 8484 ® Tank Overfill\High-Level Sensor. Model: w 'rank Overfill\High-Level Sensor. Model: p Other(specify equipment type and model in Section F,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: VR 847390.109 ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: VR 794390460 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump 1 Trench Sensor(s). Model: VR 794380-208 ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: VR 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Linc Leak Detector. Model: ❑ Electronic Line teak Detector. Model VR series 8484 ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill\High-Level Sensor. Model: ❑ 'rank 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 ❑ Dispenser Containment Sensor(s). Model VR 794380-208 ❑ Dispenser Containment Sensor(s). Model: VR 794380.208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) Dispenser ID- 05-06 Dispenser ID• 07-08 ❑ Dispenser Containment Sensor(s). Model: VR 794380.208 ❑ Dispenser Containment Sensor(s). Model. VR 794380.208 ❑ Shear Valve(s). p 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 794380-20e ❑ Dispenser Containment Sensor(s). Model VR 794380208 ❑ Shear Valve(s). ❑ 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 fort.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, (checkaU thatappty): 0 System set-up 0 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 Date of Testing/Servicing: 11/13/14