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RPR-30-2007 10:00 Service Station Systems 408 938 eee8 P.03 Monitori* System Equipmen "ertification 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 separate certification or report must be, Mpared 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 2707 Bldg.No-, Site Address: 6445 N. Pacific Ave.@ Central CL City: Stockton, CA Zip: 95207• Facility Contact Person: Aldo Contact Phone No.: (209)472.8600 Make/Model of Monitoring System: V/R TLS-35OR Date of Testing/Servicing: 419107 B. Inventory of Equipment Tested/Cerdffed Check the appropriate boxes to indicate specific equipment Inspeeted/serviecd: Tank ID: _ Tank 1D• ❑ In-Tank Gauging Probe. Model: p In-Tank Gauging Probe. Model: p Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: O Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Linc Leak Detector, Model: ❑ Mechanical Line Leak Detector. Model: a Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Modcl; ❑ 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 typo and model in Section F on Page 2). Tank IDL Tank IDL_ _ 0 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: p Mechanical Line Leak Detector. Model: 17 Mechanical Line Leak Detector, Model: O Electronic Line teak Defector. Model: p Electronic Line Leak Detector. Model: p Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E m Page 2). ❑ Olher(specify equipment type and model in Section E m Pago 2). Dispenser IDi 75 14 Dispenser ID• 16.16 M Dispenser Containment Sensor(s). Model: 1IR79u49-294 IN Dispenser Containment Sensor(s). Model: VR 794240.206 (% Sheat Valve(s). IN Shear Valve(s). (I Dispenser Contaimnent 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). p Dispenser Containment Float(s)and Chain(s). Dispenser ID•_ Dispenser ID: ❑ Dispenses Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: p Shear Valve(s). ❑ Shear Valve(6). ❑ 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 infonuation for every tank and dispenser at the facility C. Ceftifieation- t certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Cerfification is information(e.g.manufactures'eheeldists)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,f have also attached a copy of the; (check oa Mat apply): M System set-up IE Alarm history report Technician Name(print): Randy Wilkerson Signature: LbAL_. Mfg.CerL#.: A32404 ICC# 6258560-UT License,No.: 485184 Testing Company Name: Serv. Sta. SyS. _ Phone No,: _(40 971-2445 Site Addres3: 6445 N. Pacific Ave.@ Central Ct. Date of Testing/Servicing: 419107