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MAY-07-2008 12:36 Service Station Systems 408 938 8888 P.04 Monitori*System Equipment0ertification 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 reportmustet rte 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: 95207- Facility Contact Person: Elanor Contact Phone No.: 209)472-8600 Make/Model of Monitoring System: WR TLS-35OR Date of Testing/Servicing; 4/9108 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment iuspcctediserviced: Tank ID: Tank ID* ❑ In-Tank Gauging Probe. Modcl: ❑ In-Tank Gauging Probe. Madel: ❑ annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s), Model: ❑ Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector, Model: ❑ Mechanical Line Leak Detector. model: - 0 Electronic Line Leak Detector. Model: ❑ Electronic Linc Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Modd: 0 Tank Ovcrfih\I{igh-Level Sensor. Model: ❑ Other(specify equipment type and model in Section F on Page 2). ❑ other(specify equipmcnt type and model in Scction E on Page 2), TankID: Tank lDt ❑ In-Tank Gauging Probe. Mould: ❑ In-Tank Gauging Probe, Model: ❑ Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector, Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: ❑ Electronic Linc leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor, Modd: ❑ Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipmcnt type and model in Section E on Page 2). Dispenser ID: 13.14 Dispenser)(De 15.15 (g Dispenser Containment Sensor(S), Model: vn raasao.ma 13 Dispenser Containment Sensor(s). Model: VR 794380-208 IN Shear Valve(s). 19 Shea Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID• ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Scnsor(s). Model: ❑ Shear Valve(s). ❑ shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID, Dispenser ID: ❑ Dispenser Containment Scnsor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). 0 Shear Valve(s). ❑ 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 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. Attacher to this Certification is information(e g.manufactures'checklists)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,r have also attached a copy of the, (check all that apply): ❑ System set-up Cl 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: 419108