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RPR -27-2006 07:08 Service Station Systems 40B 938 eeee P.03 MonitorA 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 separate certification or report must be prepared 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: 6425 N. Pacific Ave, 0 Central CL City: Stockton, CA Zip: 95207 - Facility Contact Person: manager Contact Phone No.: (209) 472-8600 Make/Model of Monitoring System: V/R TLS-35OR Date of Testing/Setvicing: 4/10/06 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment luspected/serviced: Tank ID: 01 -Renu Tank ID- 02 -Prem 0 In - Tank Gauging Probe. Model: vR 84739at0s 0 In - Tank Gauging Probe. Model; VR 947390109 N Annular Space or Vault Sensor. Model: VR 794390420 M Annular Space or Vault Sensor. Madel: VR 794396420 i N Piping Sump \ Trench Sensor (5). Model: VR 791380.208 0 Piping Sump \ ro-ench Sensor (s). Model: VR 794393.209 21 Fill Sump Sensor (s). Model: Vol 791380-208 ® Fall Sump Sensor (s). Model: VR 794390208 0 Mechanical line teak Detector. Model; none qM Mechanical Line Leak Detector. Model: None QQ Electronic Lite Irak Detector. Madel: vR sense 8484 11 Electronic Line Leak Detector. Model: Vol saves 8484 0 Tank Overfill \ High-L.evcl Sensor, Model: Nora R Tank Overfill \ High -Level Sensor. Model: None 0 Other ( specify equipment type mid model in Section E on Page 2). 0 Other ( specify equipment type and model in Section E on Page 2), Tank ID• 03 -Diesel Tank ID. ❑ In - Tank Gauging Probe. Model: VA 847390109 0 in - Tank Gauging Probe. Model: ? ® Almulaf Space or Vault Sensor. Model: vn 794396420 ❑ Annular Space or Vault Sensor. Model: • Piping Sump\ TYewh Sensor (a). Model: VR 794300-200 0 Piping Sump\ Trench Sensor (a). Model: ? ® Fill Sump Seusor(a). Model: VR 79a396209 ❑ Fill Sump Sensor (s). Model: ? 0 Mechanical fine Leak Detector. Model Nana p Mechanical Linc leak Detector. Model: ? W Electronic Line Leak Detector. Model: vR series 8484 0 Electronic Line Usk Detector. Model: ? M Tank Overfill \ High -Level Sensor. Model: None 0 Tank Overfill \ High -Level Sensor. Madel: 7 0 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: 03.04 ® Dispenser Containment Sensor (s). Model: Va 794980-208 In Dispenser Comainment Sensor (s). Model: VR 794380200 ® Shoat Valve ($)- Ql shear Valve (s). 0 Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s)_ DispenserID: 05.05 Dispenser ID. - 07-08 09 Dispenser Containment Sensor(a). Model: VR794300-200 19 Dispenser Containmentsensor(s). Model: VR 794396209 QI Shear Valve (s). 99 Shcar valve (s). 0 Dispenser Containment Float (s) and Chain (s). 0 Dispenser Containment Float (s) and Chain (s). Dispenser ID- 09-10 Dispenser1l), 11-12 IN Dispenstt Containment Sensor (s). Model: VR 794380-208 a Dispenser Containment Sensor (s). Model: VA 794asa209 R Shear Valve (s). QO Shc;u Valve (s). Q Dispense Containment Float (s) and Chain (s). ❑ Dispenser Contaimnent float (s) acid Chain (s). +If the facility contains more tanks or dispensers, copy this form. Include information for CVCty tank and di5penser at the facility C. Certification - I certify' that the equipment identified in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information (e.g. manufactures' checklists ) necessary to verity, that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the; ( check all that apply): 0 System setup ❑ Alarm history report Technician Name (print):Matt MulCahy Signature: Mfg. Cert.#.: A28211 ICC# 5259456 -UT License. No.: 485184 Testing Company Name: Ser. Sta. Sys. Phone No-: (408) 971-2445 Site Address: 6426 N. PaCifie Ave. Q Central C1. Date of Testing/Servicing: 4/10/06