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i. Y�o ,, H Monitoring System Equipment Certifica ion � �t' b For Use By All Jurisdictions Within The State of California IIIII G O 15 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of R>��tltat rig' This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be NTA' 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 lip: 95376 - Facility Contact Person: Manager Contact Phone No.: (209) 830-2950 Make/Model of Monitoring System: VR TLS -350 Date of Testing/Servicing: 6/18/15 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/seryiced: 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 IQ: Tank ID• ❑ In - Tank Gauging Probe. Model: ❑ in - "rank 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: ❑ 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: 13-14 Dispenser ID• 15.16 ® Dispenser Containment Sensor (s). Model:VR 794380-208 ® Dispenser Containment Sensor (s). Model: VR 794390-20e ® Shear Valve (s). ® Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s) Dispenser IDe117-18 Dispenser ID• 19-20 ® 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: 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). it the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility C. Certification - 1 certify that the equipment identified in this document was inspected/seryiced 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 apply): to System set-up ® 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: 6/18/15