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FEB -13-2009 18:36 Service Station Systems 408 938 egee P.03 Monitori System Equip mentWertification Far 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. Aeparate certificatiou or reportmust be pr pared 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 Site Address:_ 6426 N. Pacific Ave. @ Central Ct. City: Stockton, CA Zip: 95207 - Facility Contact Person: Manager Contact Phone No.: 1209) 472-8600 Make/Model of Monitoring System: V/R TLS-35OR Date of Testing/Servicing: 1114/09 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate sneeific couinmenr isnerr..dmer.,ieed. Tank ID- Tank ID. - In - Tank Gauging Probe. Model; ❑ ht - Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump \ Trench Sensor (s). Model: ❑ Piping Sump \'tench Sensor (s). Model: ❑ Fill Sump Sensor (s). Modcl: ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Modcl: ❑ Electronic Lina Leak Detector. Model: ❑ E=lectronic Line Leak Detector. Model: 0 Tank Overfill \ High -Level Sensor, Model: 0 Tank Overfill \ High -Level Sensor. Model: 0 Other (specify equipment type and model in Section E on Pagc 2). ❑ Other (spxify equipment type and model in Section E on Page 2), Tank IDt Tank ID: 0 in -Tank Gauging Probe. Muriel: ❑ In - Tank Gauging Probe. Model: �— ❑ Annular Space or Vault Sensor. Modcl; ❑ Annular Space or Vault Sensor. Modal; ❑ Piping Sump \ Trench Sensor (s). Model: ❑ Piping Sump \ Trench Sensor (s). Model: 0 pill Sump Sensor (s). Model: 0 Fill Sump Sensor (s). Model: 0 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model; ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill \ High -Level Sensnr, Model: 0 'rank Overfill \ High -Level Sensor, Model: 0 Other (Specify equipment type and model in Section E on Page 2), 0 Other ( specify equipment type and model in Section E on Page 2). Dispenser ID:_ 13-14 Dispenser In- 15-16 R Dispenser Containment Sensor (s). Model:VR 794sso-2oa is Dispenser c;=inmcm Sensor (s). Model: VR raaeo.ma 0 Shear Valve (s). ❑ Shcar Valve (s). (7 Dispenser Containment Ploat (s) and Chain (s). 0 Dispenser Containment Float (s) and Chain (s). Dispenser ID- Dispenser ID: ❑ Dispeesv Containment Sensnr (s). Model: 0 Dispenser Connu mcot Senso, Is). Model: ❑ Shear Valve (s). 0 Shear Valvc(s). ❑ Dispensa Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: Dispenser ID:_ ❑ Dispenser Containment Sensor (a). Model: 0 Dispenser Containment Sensor (S). Model: ❑ Shear Valve (s). 0 Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containnieni Float (s) and Chain (s). •• — s... v .v,..mw ,trine .aims or mspcnscrs, copy mis turn. mclum mriamation 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 ) 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 it copy of the; ((Beck alt that appjy): ❑ Systcm wVup ❑ Alarm history report Technician Name (print): Randy Wilkerson Signal=: LIJ4 Mfg. Cert.#.: A32404 ICCd 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: 1114109