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FEB -13-2009 18:36 Service Station Systems 408 938 8ee8 P.O2 MonitorirQ System Equipment ..ertification 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 ofRcgulations This form must be used to document testing and servicing of monitoring equipment. A senarate certificationnr repon must be prepared for each monitoringsystemcontrol 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: Manager Contact Phone No.: (209) 472.8600 Make/Model of Monitoring System: V/R TLS-35OR Date of Testing/Servicing: 1/14/09 IL Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eouinment insrwenrt/nrvtrnm Tank ID- 01-Regu Tank ID• 024Prem IN In - Tank Gauging Probe. Model: vR 847mu-toe 13 In -'Tank Gauging Probe. Model: VR 6473m.ios 11 Annular Space or Vault Sensor. Model: VR 7/4390420 M Annular Space or Vault Sensor. Model: vR 7ssavo4w IN Piping Sump \ Trench Senor (s). Model: VR 794380.208 Oi Piping Sump \ Trench Sensor (s). Model: vR 7943w no 13 Fill Sump Sensor (s). Model: vn 79/939-209 13 Fill Sump Sensor (s). Model: VR 794390.2113 0 Mechanical Line Leak Detector. Madel: Non• 0 Mechanical Line Leak Detector. Model: Naw Electronic Linc Leak Detector. ModcCvR series 3488 IN Electronic Line I,cak Detector. Model: VR Senn 1434 ❑ Tank Overfill \ High -Level Sensor. Model: None ❑ Tank Overfill \ High -Level Sensor. Model: Nano ❑ 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 D): 03-nlnse1 Tank ID: II In - Tank Gauging Probes Model: VRU73111409 0 In - Tank Gaugmg Probe. Model: M Annular Space or Vault Sensor. Model: VR 79439orm 0 Annular Space or Vault Sensor, Model: III Piping Sump \ Trench Sensor (s), Model VR 7948/8208 ❑ Piping Sump \ Trcnch Sensor (s). Model: CK Fill Sump Sensor (s). Model: vn7243wzus ❑ Fill Sump Sensor (s). Model: 0 Mechanical Line Leak Detector. Model: Nano 0 Mechanical Line Leak Damtor. Model: M Electronic Linc Leak Detector. Model: VR aeries 8834 0 Electronic Line teak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: Non ❑ Tank Overfill 1 High -Leval Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2), ❑ Other ( specify equipment type and model in Section Eon Page 2). Dispenser ID 01-02 Dispenser ID: 03-04 M Dispenser Containment Sensor (s). Model: VR 7943811.208 13 Dispenser Containment Sensor (s). Model; vR 7s iauizoa ❑ Shear Valve (s). 0 Shear Valve (s). 17 Dispenser Containment Flom (s) and Chain (s). 0 Dispenser Containment Float (s) and Chain (s). DispenserID os Dispenser ID: 07-08 Is Dispenser Containment Scnsor (s). Model: vn 784380.208 IX Dispenser Containment Sensor (s). Model: VR 79438a -2w p shear Valve(s). ❑ Shear Valve (s). q Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID x-10 _ Dispenser ID: 11-12 Q1 Dispenser Containment Sensor (s). Model: VR 734349-29/ IN Dispenser Contaimnew Sensor (s). Model: VR 79433e0-2os 0 Shear valve (s). 0 Shear Valve (s). 0 Dispenser Containment Float (s) and Chain (s). 0 Dispenser Containment Final (s) and Chain (s). -irthe tawliry, contains mom tanks or dispensers, copy this form, Include information for every tank and dispenser at the facility C. Certification - f certify that the equipment identified in this document was lnapeeted/se"ieed in accordance with the manufacturer's guidelines. Attached to this Certification is information (e.g. manufactures' checklists ) necessary to verify that this information is correct and n 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 nes that apply). ❑ System set-up ❑ Alarm history report Technician Name (print): Randy Wilkerson Signature: LLP—. Mfg. Ceti.#.: A324O4 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: 1/14/09