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RPR -27-2006 07:08 Service Station Systems 408 938 8888 P.04 MonitoriAl System Equipment certification For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 6.7, Health and Safety Cade; 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. @ Central Ct. City: Stockton, CA Gip: 96207 - Facility Contact Person: manager Contact Phone No.: (209) 472-8600 Make/Model of Monitoring System: V/R TLS -3508 Date of Testing/Servicing: 4/10/06 B. Inventory of Equipment Tested/Certified Check the aporonriate boxes to indicate specific equipment it Tank ID: Dispenser ID- 15-16 ® Dispenser Contairtmmt Sensor(s). Mode):ya7ai3a 208 • in - Tank Gauging Probe. Model: ? ❑ Annular Space or Vault Sensor. Model: ? l7 Piping Sump \ Trench Sensor (s). Model: ? O Fill Sump Sonsor (s). Modcl: ? 13 Mechanical Line Leak Detector. Model: ? ❑ Electronic Line teak Detector. Model: ? ❑ Tank Overfill \ High -Level Sensor. Model: 7 (7 Other ( specify equipment type and model in Section E an Page 2). Tank ID. Dispenser ID- 15-16 ® Dispenser Contairtmmt Sensor(s). Mode):ya7ai3a 208 D In - Tank Gauging Probe. Model: 7 E3 Annular Space or Vault Sensor. Model: ? p Piping Sump \ Trench Sensor W. Model: ? p Pill Sump Sensor(s). Model: ' O Mechanical Line Leak Detector_ Model: ' 0 Electronic lane Leak Detector. Model: ? ❑ Tank Overfill \ High -Level Sensor. Motel: 7 (] Other ( specify equipment type and model in Sectim E on Page 2). Tank ID: Dispenser ID- 15-16 ® Dispenser Contairtmmt Sensor(s). Mode):ya7ai3a 208 ❑ In - Tank Gauging Probe. Model: ? ❑ Annular Space or Vault Sensor. Model: ? 17 Piping Sump \ Trench Sensor (s). Model: ? 0 Pill Sump Sensor (s), Model: ? ❑ Mechanical Line Leak Detector, Model: ? ❑ Electronic Line Leak Detector. Model: ? ❑ Tank Overfill \High -Level Sensor. Model: 7 Cl Other ( specify equipment type and model in Section E on Page 2). Tank TD- Dispenser ID- 15-16 ® Dispenser Contairtmmt Sensor(s). Mode):ya7ai3a 208 D In - Tank Gauging Probe. Model: Cg Slucir Valve(s). ❑ Annular Space or Vault Sensor. Model: ? ❑ Piping Sump \Trench Sensor (s), Model: ? (7 Fill Sump Sensor (s). Model: ? (7 Mechanical Line Leak Detector. Model: ? p Electronic Line Leak Detector. Model: ? ❑ Tank Overfill \High -Level Sensor'. Model: ? p Other ( specify equipment type and model in Section E on Page 2), Dispenser ID• 13-14 Dispenser ID- 15-16 ® Dispenser Contairtmmt Sensor(s). Mode):ya7ai3a 208 N Dispenser ConLwtment Sensor (s). Mode): ern 79438N2602 p Shearvalve(s). Cg Slucir Valve(s). ❑ Dispenser Containment Float (s) and Chain (s). Q Dispenser Containment Float (s) and Chain (s). Dispenser ED- Aispenser ID — ❑ Dispenser Containment Sonsor(s). Mot& 7 0 Dispenser Containment Sensor(s). Model: ? ❑ Shear Valve (s). p Shcar Valve (s). p Dispenser Containment Float (s) and Chain (s). (3 Dispenser Containment Flnst (s) and Chain (s). Dispenser IDL Dispenser ID. ❑ Dispenser Comamment Sonsor(s). Model: ❑ Dispenser Containment Sensor (s). Model: ❑ Shear Valve (s). t7 Shear Valve (s). tl Dispenser Containment Float (s) and Chain (s). O Dispenser Containment noat (s) and Chain (s). -if the facility conmins 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 hispectedtlerviecd in accordance with the manufacturer's guidelines. Attached to this Certification is information (e.g. manufacture%' 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; (chock all that apply): ❑ System set-up 0 Alarm history report Technician Name (print): Matt Mulcahy Mfg. Cert.#.: A28211 ICC# 5259456 -UT Signature: - License. No.: 485184 Testing Company Name: Ser. Sta. SYS. Phone No.: (408) 971-2445 Site Address: 6425 N, Pacific Ave. @ Central Ct. Date of Testing/Servicing: 4/10/06