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MAY -19-2005 20:00 Seruice Station Systems 408 938 8888 P.03 Monitori# System Equipment Oertification 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 Ct. City: Stockton, CA Zip: 952047- Facility Contact Person: Eleanor Contac[ Plfone No.: (209) 472-8600 Make/Model of Monitoring System: V/R TLS-36OR Date of Testing/Servicing: 4/19/05 B. Inventory of Equipment Tested/Certifled r•t....t, et.. o....mnrinrn hnvna to indtrate anecific eauioment insueaed/eerWttd: "If the facility contains more tanks or dispenses, copy this form. Include mlormatmn for every tarn ano otspcnser in orae racemy C. Certification - I certify that the equipment identified in this document was irepecled/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information (e.g. manufactures cbectdists ) 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, I have also attached a copy of the; ( check all that apply): U System set-up ❑ Alarm history report Technician Name (print): SSS-RaulS Signature: R, . d...«d d. Certification No.: 006.050833 License. No.: 485184 Testing Company Name, Ser. Stec. SYS. Phone No.: (408) 971-2445 Site Address: 5425 N. Pacific Ave. @ Central Ct, Ditto of Testing/Servicing: 4/19/05 Tank ID Tank IDL 0 In - Tank Gauging Probe. Model: ? 0 In - Tank Gauging Probe, Model: 7 a Annular Space or Vault Sensor. Model: ? ❑ Annular Space or vault Senwr. Model: ? ❑ Piping Sump \ Trench Sensor (s). Model: ? 13 Piping Sump \Trench Sensor (s). Model: Cl Fill Sump Sensor (s), Model: ? ❑ Fill Sump Sensor (s). Madel: ? p Mechanical Linc Leak Detector. Model: ? ❑ Mechanical Line Irak Detector. Model ? p Electronic line Irak Detector. Model: ? M Elecaonic Line Leak Dtaector. Model: 9 ❑ Tank Overfill \ High -Level Sensor. Modeh ? ❑ Tank Overfill \ High -Level Sensor. Model: ? ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ Other ( specify equipment type and model in Section E on Page 2). Tank ID TankID E3 In -Tank Gauging Probe. Model: q ler - Tank Gauging Probe. Madel: '+ ❑ Annular Space or Vault Sensor. Model: 7 0 Annular Space or Vault Sensor. Model ? E3 Piping Sump \Trench Soni r(s). Model: ? p Piping Sump\Trench Sensor (s). Model: ? 13 Pill Sump Sensor (s), Model: ? p Fill Sump Sensor (s). Model: ? p Mechanical Line leak Detector. Model: ? p Mechanical Line Leak Detector. Model: ? p Electronic Linc Leak Detector, Model ? p Electronic Line Lcak Detector. Model: ? Cl Tank Overfill \ High -Level Sensor. Model: ? ❑ Tank Overfill \ High -Level Sensor. Mold: ? ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ Other ( specify equipment typo and model in Section E on Page 2). Dispenser ED, tsta Dispenser EMD, 15-16 a Dispenser Containment Sensor (s), Model: vn?9a3aa2os N Dispenser Containment Sensor (s) Model: Va?91aa�aea if Shear Valve (s). QI Shear Valve (s). d Dispenser Contaimmnt Float (s) and Chain (s). p Dispenser Containment Float (s) and Chain (s). Dispenser ID' Dispenser ID• — [] Dispenser Containment Sensor (s). Model: ? ❑Dispenser Contavuneltt Sensor (s). Model: ? p Shear Valve (s). ❑ Shear Valve (a). p Dispenser Containment Float (s) and Chain (s). O Dispenser Containment Float (s) and Chain (a). Dispenser ID- Dispenser ID, Ll Dispenser Centainmcnt Sensor (s). Model: ? ❑ Dispenser CcmainmentScmor(s). Model: ? U Shear Valve (s), O Shear Valve (s). p Dispenser Containment Plant (s) and Chain (s). O Dispenser Containment Float (s) slid Chain (s). "If the facility contains more tanks or dispenses, copy this form. Include mlormatmn for every tarn ano otspcnser in orae racemy C. Certification - I certify that the equipment identified in this document was irepecled/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information (e.g. manufactures cbectdists ) 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, I have also attached a copy of the; ( check all that apply): U System set-up ❑ Alarm history report Technician Name (print): SSS-RaulS Signature: R, . d...«d d. Certification No.: 006.050833 License. No.: 485184 Testing Company Name, Ser. Stec. SYS. Phone No.: (408) 971-2445 Site Address: 5425 N. Pacific Ave. @ Central Ct, Ditto of Testing/Servicing: 4/19/05