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RPR-30-2007 10:00 Service Station Systems 408 938 8888 P.02 Monitories System Equipmen :ertification For Use By All JNrisdietions 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 forth must be used to document testing and servicing of monitoring equipment. A separate certification or report must be nreoared 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_SaTeway 2707 _ Bldg.No.; Site Address: 6445 N. Pacific Ave. @ Central Ct. City: Stockton, CA Zip: 95207- Facility Contact Person: Aldo Contact Phone No.; (209)472-8600 Make/Model of Monitoring System: WR TLS36OR Date of Testing/Servicing: 4/9/07 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank IDk Gauging Tank ID- 02-Prem T n -Tank Gauging Pmbe. Model: VR U73WIDS 19 In-Tank Gauging Probe. Model: VR 947390-109 13 Annular Space or Vault Sensor. Model: VR 794390420 ri Annular Spacc or Vault Sensor. Model: ya7543w0 M Piping Sump\Trench Sensor(s). Model: VR 704MO-208 0 Piping Sump\Trench Sensor(s). Model: vR n43e0.20e 13 Fill Sump Sensor(s). Model: YR 784390QDS p( Fill Sump Sensor(s). Model: VR 721190.208 ❑ Mechanical Line Leak Comm Model: Non. ❑ Mechanical Line Leak Detector. Model: Ron• (I Electronic Linc Leak Detector. Model: VR sane•94e4 0 $lectronic Line Leak Detector. Model: yR sense 9494 0 Tank Overfill\high-Level Sensor. Model: Nene ❑ Tank Overfill\High•Lcve1 Senior. Model: Nano 0 Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E as Page 2). Tank ID• 03-Diesel Tank ID: (g In-Tank Gauging Probe. Model: 9R 9473a0.10s ❑ In-Tank Gauging Probe, Model: CK Annular Space or Vault Sensor. Model: VR 794390420 ❑ Annular Space or Vault Sensor, Model: M Piping Sump\Trench Sensor(s). Model: VR 794390.209 ❑ Piping Sump\Trench Sensor(s). Model: CK Fill Sump Sensor(s). Model: VR 794380.209 ❑ Fill Sump Sensor(s). model! — 0 Mechanical Line Leak Detector Madel: Nene ❑ Mechanical Line Leak Detector. model; — M Electronic Line Leak Detector. Madcl: VR sod"9484 ❑ Electronic Lino Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Modcl: None 0 Tank Ovcffill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Dispenser ID,, 01-02 _ Dispenser ID; 03-04M Dispenser Containment Sensor(s). Model VR 7%380-ec0e IN Dispenser Containnxnt Sensor(s). Model: VR 794100-209 IN Shear Valve(s). IN Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser tD: OS-06 Dispenser EN 07.08 19 Dispenser Containment Sensor(S), Model: VR 7943BD—U OI Dispenser Containment Scnsor(s). Model: VR 704no.ma t% Show Valve(s). 13 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser IDs 09.10 Dispenser ID• 11.72 IN Dispenser Commmnlent Sensor(s), Model: VR 794390.209 (g Dispenser Containment Sensor(s). Model: VR 794390-200 a Shear Valvc(s). QI Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispciucr Containment Float(s)and Chain(s). *If the 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 inspeeled/scrviced 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 Plut Plan showing the layout of monitnring equipment. For any equipment capable of generating such reports,1 have also attached a copy or the; (check all that apply): M System set-up IN Alarm history report Technician Name(print): Randy Wilkerson Signature: Mfg.Corr*: A32404 ICC# 5258560-UT License.No.: 485184 Testing Company Name: Serv. Sta.Sys. Phone No.:_(408)971-2445 Site Address: 6445 N, Pacific Ave. @ Central Ct. Date of Testing/Servicing: 4/9/07