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MRY-07-2008 12:36 Service Station Systems 408 938 99ee P.03 Monitori _ System Equipmenteertification For Use By All Jurisdictions Within The State of California Authority Cited., Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 13, California Code of Rcgulatinin This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be p=med 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 Zip; 95207- Facility Contact Person: Elanor Contact Phone No.: (209)472-8600 Make/Model of Monitoring System: V/R TLS-35OR Date of Testing/servicing; 4/9108 B. Inventory of Equipment Tested/Certified Cheek the appropriate boxes to indicate specific equipment inspected/serviced: Tank IR:_01-Regu Tank ID- 02-Prem IX In•Tank Gauging Probe, Model: VR 947398-199 IX In-Tartk Gauging Probc, Model: VR 947390.199 IN Annular Space or Vault Sensor. Model: VR 7%sn"eo (3 Annular Sparc or Vault Sensor. Model; VR 7943BOJ6o IS Piping Sump\Trench Sensor(s). Model: VR75,13M20131 IN Piping Sump\Trench Sensor(s). Model: yrs 75360-Coe IX Fill Sump Sensor(s)- Model: M79,1380-208 M Fill Sump Sensor(a). Model: VR 79380-209 ❑ Mechanical Line Irak Detector- Modcl: Nana ❑ Mechanical Line Leak Detector- Model: Nene gl Electronic Line Leak Detector. Model: VR serte.a,1e4 IS Electronic Line Leak Detector. Model: VR swiss 8484 ❑ Tank Overfill\High-Level Sensor. Model: Noes ❑ Tank Overfill\High4,cvel Sensor. Model: Nene ❑ 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 IQ; 09-Diesel Tank IDS CK [n-Tank Gauging Rotes, Mode(: yR847393.1m ❑ In-Tank GaugingPmbe. Model: Annular Space or Vault Sensor. Model: V117943040 ❑ Annular Space or Vault Sensor. Model: cc Piping Sump\'french Sensor(s). ModeC VA 79430-203 ❑ Piping Sump\Trench Sensor(s). Model: IH Fill Sump Sensor(3), Model; VR 794700-233 ❑ Fill Sump Sensor(s), Model: ❑ Mechanical Linc Leak Detector. Model: Nom p Mechanical bine Leak Detector. Model: M Electronic Line Leak Dow,or, Model: VR Seri"6414 ❑ Electronic Line Leak Detector. Modcl: ❑ Tank Overfill\High-Level Sensor. Modal: None ❑ Tank Overfill\tligh-Leve(Sensor. Model: ❑ 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 1D- 01-02 =7243U-208 Os-D4 peDispenser IDS 0t Dispenser Containment Sensor(s). IX Dispenser Containment Sensor(s), Model: VR 7%360-208 IX Shear Valve(s). tit Shear Valve(s). 0 Dispenser Containment Float(s)and Ch ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID.• 05.08 Dispenser ID: 07.08 IX Dispenser Containment Sen3or(s). Model: VRI MMU-206 pt Dispenser Conminmcnt Scnsor(s). Model: VR 794360206 IX Shear Valve(s). IX Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). p Dispeaticr Coniainmcnt Float(s)and Chain(s). Dispenser ID: 09.10 Dispenser 1D: 11.12 IS Dispenser Containment Senwu(%). Model: Ant7sta8o-201 [I Dispenser Containmem Sensor(s). Model: VR 784 N.= CX Shear Valve(s). 13Shear Valve(s). El Dispenser Containment Float(s)find Chain(s). ❑ Dispenser Containment Plow(s)unit Chain(s). Cif 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 inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'Checklists)ri"asary 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 ofthe; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name(print): Randy Wilkerson Signature: / . Mfg.Cert.#.: A32404 ICC# 5258560-UT License.No.: 485184 Testing Company Name: Serv. Sta. Sys. Phone No.; (408)971-2445 Testing Company Address: 680 Quinn Ave., San Jose CA 95112 Date of Testing/Servicing: 419/06