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RPOEIVED Monitoring System Equipment Certiiicat�?C� 2 zo�4 F'or Use By All Jurisdictions Within The State of California Authority Cited: Chapter 6. /7, Health and Safety Code; Chapter 16, Division 3, Title 23, C.,'alifo nia Code of Regulations NVIR01 i This form must be used to document testing and servicing of monitoring equipment. a t rtiftcati n rtmust be °-IEALTH prepared for each monitoring system control � by the technician who performs the work. A copy of this rm7frmst be.provickd 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 IQ* 01-Regu -tank ❑ ID• 02 -Prem In - Tank Gauging Probe. Model Vit $47390-109 ❑ In - Tank Gauging Probe. Model. VR 947390.199 ❑ Annular Space or Vault Sensor, Model: VR 794390.490 ❑ Annular Space or Vault Sensor. Model: VR 794390-460 0 Piping Sump \ Trench Sensor (s). Model: VR 794380-208 ❑ Piping Sump \ Trench Sensor (s). Model: VR 794380.208 ❑ Fili Sump Sensor (s). Model: VR 794380-203 ❑ Fill Sump Sensor (s). Model: VR 794380.208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: a Electronic Line Leak Detector. Model: VR seri" 8484 ❑ Electronic Line Leak Detector. Madel: VR Sertea 9484 ❑ Tank Overfill i, High -Level Sensor. Model: p 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• 03 -Diesel Tank IQ* [I In - Tank Gauging Probe. Model: VR 841390.109 ❑ In - Tank Gauging Probe, Model.- odel:❑ 0 Annular Space or Vault Sensor. Model: VR 794390.460 ❑ 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 ❑ Fill Sump Sensor (s). Model• ❑ Mechanical Line Leak Detector. Model: _ ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Deu:ctor. Model: VR series 8484 ❑ 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). Dispenser ID' 01-02 Dispenser ID- 03-04 ® Dispenser Containment Sensor (s). Madel. 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 N Dispenser Containment Sensor (s). Model VR 794380.208 ® Dispenser Containment Sensor (s). Model VR794380-208 ❑ 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 tj Dispenser Containment Sensor (s). Model vR 794380-208 11 ® 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). *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 verity 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 tile; (cheek all that apply): ® System set-up ® Alarm history report Technician Name (print): Kris Bell Signature: Mfg. Cert.#. B33709 ICC# 5297793 -UT Testing Company Name: Service Station Systems Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 License. No.: 485184 Phone No.: (408) 971-2445 — Date of Testing/Servicing: 11/13/14