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CEIVED 1 Monitoring Y Equipment System E ui ment Certification For Use By All Jurisdictions iflithin The State oj'California DEC 12 2014 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 certific ffi&rt must be �EA�TH prepared for each monitoring system control panel by the technician who performs the work. A copy of this formEOust 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: 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 inspected/sen iced: 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 teak 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 IQ Tank W: ❑ 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. 0 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model ❑ 'rank 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) Dispenser IDs 13-14 Dispenser ID• 15-16 ❑ Dispenser Containment Sensor(s). Model: VR 794380-208 ❑ Dispenser Containment Sensor(s). Model. VR 7WBO-208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser IQ: 17`18 Dispenser IIS• 19-20 ❑ Dispenser Containment Sensor(s). Model: VR 794380-208 ❑ Dispenser Containment Sensor(s). Model vie 794380.203 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *Ifthe 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 app(v): ® System set-up ® Alann 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