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Monitoring System Equipment CeRification For Use By All Jurisdictions Within The State of California qurhorio,Cited*Chapter 6.7. Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations 'his form trust be used to document testing and servicing of monitoring equipment, A separate certificationr re ort must be r arcd for each monitoring system control ranel by the technician who performs the work. A copy of this form must be provided ro the tank system owner/operator. mic owner/operator most submit a copy of this form to the local agency regulating UST system within 30 days of test date. k. General Information "acility Name: Safeway 2425 Bldg,No.- iite Address; 6425 N. Pacific Ave. Central Ct. City: Stockton, CA Zip: 952 Contact Phonc Nu.: acility Contact Person: 20J 4 J /"6 Make/Model of Monitoring System: ? V� 96Z)T' 7-2�5-14P—DateofTcsting/Setvicing: 4H5f2EC+k" 2K, v/ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspeetedlserviced: Tank m•at- 0 b r k ID: 02- ea1M l /�In-Tank Gauging Probe. Model: 7 in-Tank Gauging Prolx. Model:. 7 ,_g^ Mnular Space or V cult Sensor Mod : 7Annular Space or Vault Sensor. Model ?119, b Piping Sump\Trench Sensor(s). Model: 7 + ppiping Sump\Trench Sensor(s). Model: v U .,g Fill Sump Sensor(a). MaleI ? �Fill Sump Sensor(s). Model:7� yid �p V1,Annic2l t.inc teak Detector. Model: 7 ❑ Mechanical Line Usk Detector. Model: ? ,B. Electronic Line Lcak Detector. Model; ? 2P Electronic Linc Leak Detector. Mesad: 7 ❑ Tank Overillll\High-Level Sensor. Model: 7 p Tank Overfill\High-IAvel Sensor, Model: 7 ❑ Other(specify equipment type and model in Section Eon Page 2). ❑ Other(specify equipment type and model In Section Eon Page 2). Tank ID- 03- 1b TankID tVIn-Tank Gauging Probe. Model: 7 In-Tank.Gauging Probe. Model: 7 Annular Space or vault Sensor, Model: > Annular Space or Vault Sensor. Mndrh ? Piping sump\Trench Sensor(s). Model: 7 p Piping Sump\'trench Sensor(s). Model: ? Fill Sump Sensor(s). Modal: 7 �p Fill Sump Sensor(s). Model: 7 ❑ tyLachallreul Liu.Leek Dcteator. Model: ? ❑ Mnnhnnunl Line T.cak Detector. Madel: ? Elechonic Line Leak Detector. Model: ? 516E1ccamnit Line Leak Detector. Madel: 7 ❑ Tank overfill\High-Level Sensor. Model: ? p Tank Ovcrfll\High-Level Scnscr. Model: ? ❑ Other(specify equipment type and mr&I in Snetinn E on Pace 2). CI Otho(specify equipment type and modal in Section E on Page 2). Dispenser ID- IM- ispenser ID j?Dispenser Containment Sensor(s). Model: 7 �DispcnscrConte2mman6sor(s). Model: ? ❑ Shcar Valve(s), ❑ Shear valve(s). ❑ Dispenser Containment Float(s)and Chain(s), Cl Dispenser Containment Float(s)and Chain(s). Alspenser ID' 03- operas*ID- - ]pb,spenser Containment Sensor(s). Madel: ? Wispenser Containment Sensor(s). Model: ❑ Strait Valve(s), p Shear Valve(s)- p Dispenser Containment Float(s)and 0,-in(a). ❑ Dispenser Containment Float(s)and Chain(s). r Dispenser ID• as. Dispenser ID �{Dispenser Containment Sensor(s). Model: isPLM&er Containment Sensor(s). Model: > Shear Valve(s). ❑ 9he'u Valeo(s). ❑ Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). -if d,e manicy taurines mnre.tnnkq nr dispensary,copy this form.include information far every tank and dispenser at the facility C.Certification- I certify that the equipment identified in this document was inapmtediservlced in accordance with the mannfnrmrnr's enldnlines. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verify that(ills information is correct and a Plot Plan showing the layout of monitoring equipment Por any equipment capable of generating such reports.I have also attached a copy of the; (check all that apply): JppSystem set-upLila tH to, report Technician Name(print); SSS-Talbott L / Signature; `� Certification No.: � -3 J I ` 77� License, N 5184 Testing Company Name: Ser. Std. Sys. Phone No.: (408)971.2445 Site Address: 6425 N. Pacific Ave. (p) Central Ct. bate of Testing/$crvicing; � �/a9 Z0 39Vd ONI SSS GETOTL680V 55:95 p00Z/0Z/50