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JIJL-14-2011 10:56 Service Station Systems 408 938 ee88 P.03 Monitoring System Equipment Certification 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 fort must be used to document testing and servicing of monitoring equipment. A separate certification gr report must be preeared 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. City: Stockton, CA Zip: 95207- Facility Contact Person: Manager Contact Phone No.: (209) 472-8600 Make/Model of Monitoring System: V/R TLS-350 Date of Testing/Servicing: 6/20/11 B. Inventory of Equipment Tested/Certified Check the appropriate hoe4:6 to indicate specific equipment inspected/serviced: Tank ID-01-Regu Tank IR* 02-Pram ® In-Tank Gauging Probe. Model; VR 147350.109 0 In-Tank Gauging Probe. Mndeh vR 047380.108 0I Annular Spam or Vault Sensor. Model; VR 784aao.480 ® Annular Space or Vault Sensor, Model: VR794383r60 • Piping Sump\Trench Sensor(s). Model: VR 794340400 a Piping Sump\Trench Sensor(s). Model: VR 794336.20A ® Fill Sump Sensor(s). Model: VR 794340-208 N Fill Sump Sensor(s). Model: VR 794ae0.208 Q Mechanical Lino Leak Detector. Model; ❑ Mechanical Line Leak detector, Model: ® Electronic Linc Leak Detector. Modch yR Sodes 8184 0 Electronic Line Leak Detector, Model: VR sense 8484 ❑ Tank Overfill t High-Level Sensor, Model: ❑ Tank Overfill\High-Level Sensor. Mode(; ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section F•on Page 2). Tank ID,03-Diesel Tank ID ® In-Tank Gauging Probe. Model: VR e4730499 Cl In-Tank Gauging Probe. Model; M Annular Spam or Vault Sensor. Model: VR 184090460 ❑ Annular Spam or Vault Sensor. Model: ® Piping Sump\Trench Sensor(i). Model: VR 794360-M ❑ Piping Sump\Trench Sensor(s). Model; M Fill Sump Seoanr W. Model: va794380.238 ❑ Fill Sump Sensor($)- Model: ❑ Mechanical Line leak Detector. Model: ❑ Mechanical Line Leak Detector. Model; ® Electronic Line Leak Detector. Model: VR Banes As" ❑ Electronic Linc Lcak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E oil Page 2). Dispenser ID- 01.02 Dispenser ID- 03.04 I& Dispenser Containment Sensor(s). Model: VR704380400 ® DispenscrCmtminment Scnaor(s). Model: VR 784380.238 ® Shear Valve(s). ® Shoar Valve(a). q Dispenser Containment Float(s)and Chain(a). ❑ Dispenser Containment Float(a)and Chain(s). Dispenser ID 05 06 Dispenser 1%07-0 ® Dispenser Containment Sensor(s). Model: VR 794306.208 ® Dispenser Containment Sensor($), Model: VR 794184203 R Shear Valve W. ® Shear Valve(s). q Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain($). Dispenser ID: 09"10 _ Disppenser IDt 11.12 2 Dispenser CAntainment Scmor(s). Model: vR754aaaaaa 0 Dispenaer Containment Sunsur(s). Me&]: VR 784360.208 ® Shear Valve(s). a Shear V41ve(s). ❑ Dispenser Containment Float(a)and Chain(s), ❑ Dispcnacr Conminmenl Plou(s)and Chain(s). ,if the facility contains more tanks or dispensers,copy this form,Include infomtation for every tank and dispenser at the facility C.Certification- I certify that the cquipmeal identified In this document was inspectedlierviced in accordance With the manufacturer's guldelines. Attached to this Certification is information(e.r,manufactures'checklists)necessary to verify that this information i9 correct and a Plot Plan showing the layout of monitoring ctioli tnent, For any equipment capable of generating such reports,I have Also attached a copy of the; (check a0 dtatatyily): ❑ System set-Rp ❑ Alarm history report Technician Name(print): Bryan Lundien _ Signature: Mfg. Ccrt.#.: 1336094 ICC.# 8001468•UT License.No.: 485184 Testing Company Name: Service Station Systeme Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 6120111