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Monitoring System Equipment Certification For Use By All Jurisdictions Within The State of California 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 se arate certification or report must be re ared for each mcmitntin S-Stem control panel by the technicianwho perforins 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 2425 Bldg.No._,,, Site Address: 6425 N. Pacific Ave. Central Ct. City: Stockton, CA Zip: 95204- Facility Contact person: Convect P)turtc No.: (200) 111-1111 Make/Model of Monitoring System: ? Date of Testing/Servicing;: 4115/2004 B. Inventory of Equipment Tested/Cer ified Cheek the appropriate boxes to indicate specific equipment inspected/serviced: Fauk ID: Tank ID ❑ In-Tank Gaugmg PYobc. Model: 7 ❑ In-Tunk Gauging Probe. Model: '+ ❑ Annular Sparc or Vault Sensor Muriel: ❑ Annular Space or Vault Sensor. Model: "+ ❑ Piping Sump 1 Trench Sensor(s). Model: ? ❑ riping Sump\Trencn sensor(s). Muddy 7 ❑ Fill Sump Sensor(s). Model: '+ p Fill Sump Sensor(s). Model: '+ ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Dctccmr. Model: 7 ❑ EleCh'onic Ltnc Leak De[ecmr. Modell 7 P Elwumdc u��e L.oa1.Demao�. Madel ❑ Tank OvelTrll\High-Level Sensor. Model; ? ❑ Tank Overfill\High-Le:-el Sensor. Madel: '+ 0 Other(specify equipment type and model in Section E on Page 2). ❑ Other(sptdfy equipment type and model in Section E on Page 2). Tank ID Tank ID ❑ In-Tank Gauging Probe. Model: ? ❑ In-Tank Gauging Probe. Model: a ❑ Annular Space or Vault Sensor. Model ? r1 Annular Space or Vault Sensor. Mode(: 7 ❑ Piping Sump\Trench Sensor(s). Model: 7 ❑ Piping Sump\'french Sensor(s)- Model:� ❑ Fill Sump Sensor(s), Model: 7 ❑ Fill Sump Sensor(s). Model: 7 p Ivtechnnleol Line leak Dmucrnr. Modal: ? Cl Mechanical Linc Leak Detector, Model: 7 ❑ Flecironic Line Leak Detector. Model: 7 ❑ Electronic Line Leak Daccmr. Model: ? ❑ Tank Overfill\High-Levet Sensor. Modcl: ? ❑ Tank Overfill\High-Level Service. Model: ? ❑ Other(specify equipment type and model in Section E an Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Dispenser ID• Dispenser ID- D8- Dispenser Containment Sensor(S). Model: ? - ❑ Dispenser Conreinment Sensor(a), Model! ? shear Valve(s). ❑ Shear Valve(a). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). .penxer 7n..Q! .. Dispenser ID• 1D- DispenserContainmentSensor(sj. Model: ?� ❑ Disponscr Containment Scnsor(s). Model: -r ❑ Shcar Valve(s). ❑ Shear valve(s). Float(s)and Chain(s). ❑ Dispenser Containment Float(S)and Chain(0- I r Dispenser ID- 12- ispenscrContainment Sensor(s). Model: 7 ❑ Dispenser Containment Sensor(5), Model: 7 shear Vale(a). ❑ 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 form.Include information for every lank and dispenser at the facility C. Certification- 1 certify that the equipment identified In this document was inspectedAerviced in accordance with the inatu facmrer's guidelines. Attached to this Certification is infarmntion(e.g.manufactures'checklists)necessary to verify that this information Is correct and a Plot Plan Showing the layout of monitoring equipment. tror any equipment capable orgeneradrig such reports,I have alsu attached a copy of the; (check all than appl)q: ❑ System set-up ❑ Alarm history,report Technician Name(print): SSS-Talbott Signature: Certification No,; License.No.: 485184 Testing Company Namc Ser. Sta. Sys. Phone No.: (408) 971-2445 Sirc Addrvm; 6425 N. Pacific Ave. o-Central Ct. nate of Testing/Servicing: 411512004 60 39Vd 9NI SSS SE10IL6001, 99:9I b00Z/0Z/S0