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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 Safetv Code; Chapter 16, Division 3, Title.23, California Cotte of Regulations This form must be used to document testing acrd servicing o£monitoring cquipment. A separate certification or report must be prepared for each monitotinA sv_ctem control Hanel by the technician who performs the work. A copy of this form must be provided co lbv 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 Nam a: Safeway 2707 Bldg.No.: Site Address; 6425 N. Pacific Ave. @ Central Ct. City: Stockton, CA Zip: 952047- Faeilzly Contaei Person: Stan Contact Phone No.: (209) 472.8600 Make/Model of Monitoring System: VIR TLS-350 Date of Testing/Servicing: 4/20104 B. Inventory of Equipment Tested/Certified Cl eck thv appropriate boxes to Ins icate specific equipment inspect allserviced: TanklD: W ,❑ In-'Tank Gauging Probc. Model- 7 ank Gauging Probe. Model:❑ Annular Space or Vault Sensor. Model• 7 lar Space a•Vardt Sensor. ModeL❑ PipingSump\Trench Sensor(s). Model: 7 Sump\Trench Savor(s). Model:❑ Fill Sump Sensor(s). Model: 7 mp Sensor(F). Model: 7 ❑ Mechanical Line Leah Nastier. Model: P anical Line Ltaik Detector. Model: 7 ❑ Irleclnule tine I.CAx Uctcetor. Modcc V muc Line Leak Detector. Model: 7 Tank Overfill\High-LevelSensur. Madel: 7 Overfill\High-level Sensor. Modal: 7Other(sped y cquipment type and model in Section E on Page 2). (specify equipment type and model in Section E on Page 2). Tank1D: TauklD- ❑ hl-Tank Gauging Probe. Model: t ❑ In-Tank Gauging Probe. Model: 7 ❑ Annidar Sryu:e or Vanh Snncnr. Madrl: 7 ❑ Anmdnr gpnrr nr Vnnll Srnanr MM'I 7 L'J Piping Sump\'french Sensor(s). Model: 7 ❑ Piping Sump\Trench Sensor(s). Model: 9 ❑ Fill Sump Sensor(s). Model: 7 ❑ Fill Sump Sensor(a). Madel: 7 ❑ Mechanical Line Leak Detector. Model: . ❑ Mechanical Linc Leak Detector, Model: 7 ❑ Mcc ronic Line Leak Detector. Model: 7 ❑ Electronic Line Leak Detector. Model:? ❑ 'fank Ovcrtil\High-Level Sensor. Model: 7 ❑ Tank Overfill\High-Level Sensor. Model: 7 ❑ 011ier(specify equipment type and=del in Section F on Pagc 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser D- 13.14 Dispenser ID: 15-is ® DlSpeaser C'unuumment SCltsur(a). Mudel: yR 995580-208 ® Dispenser('eniaininent$enaro'(5). Model: Va 794300-zoo ❑ Slid.Vulvc(+). ❑ 311Gl V;ilve W. p Dispenser Containment Float(s)and Chain(s), ❑ Diapanwr C'untuinmunt Final(s)and Chain(s). Dispenser ID: .._._..__ Dispenser 1D: ❑ Dispwscr Containment Sensor(s). ModeL 7 ❑ 17ixpunscr Containment Sensor(s). Model: 7 ❑ Sheer Vulvc(s). ❑ Shear Valve(s). ❑ Dispenser Containment Final(s)and Chein(s). ❑ Dispenser Cnntainmcntl=loal(s)and Cluin(s). Dispenser ID• Dispenser ID, ❑ Dispenser C'unmiiiment Sensor(a). Mndcl: 7 ❑ Dispenser Contain mcnl Season(s). Model: 9 ❑ vnr•,r v,lv,•(s) O Rhear VlIve(s). Cl Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Cuntainment Flout(s)and Chain(s). "if the f6lity contains more tanks or dispenxea,copy this form.include infomlation for ever)tank and dispenser at the facility C. Certification- i certify that the equipment identified in this document was inspected/serviced in accordance with the nulnufaeturer's puidelinm. Attached to this Certification is information(e.g.manufactomm'checklists)necessary to Verify that this information is correct and a Plot Plan Showing theleyout of monitoring equipment. Far any equipment capable of generating such reports.I have alsu attached a copy of the: (rkeek all Mot applv)r ❑ System set-up ❑ Alarm history report Technician Nante(print): S$$-Talbott Signature: Certification No.: 000-00-5772 License.No.: 485184 -['CstingCompany Name: Ser.-Sta. Sys. Phone No.: (4081971-2445 Site Address: 6425 N. Pacific Ave. @Central Ct. Date of Testing/Sorvicing, 4/80/04 90 39VcJ DNI SSS 9810IL680P 99:91 b06Z/0Z/90