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RUG-12-2010 09:10 Service Station Systems 409 938 8888 P.02 MonitoriQ System Equipment ;ertification For Use RY All Jurisdictions Within The State of California Authdrity 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 senarato certifies bn or report must be 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 ownerioperator. 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 — BldL.,No.: Site Address: 6425 N. Pacific Ave. City: Stockton, CA Zip: 95207- Facility Contact Person: a t c, Contact Phone No.: (209) 472-8600 Make/Model of Monitoring System: y I g— Date of Testing/Servicingff: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific cgnipment Inspected/serviced: Tanklb 9 7 —Z TanklD ❑ In-Tank Gauging Probe. Model: ❑ In•Tank Gouging Probe. Model: ❑ Annular Space"Vault Sensor. Model: ❑ Annular Space or vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: p Mechanical Line Leak Detector. Model: S}.• Electmnic Line Leak Detector. Model: (0• Electnmic Line Leak Detector. Model: ❑ Tank Overillt\High-Level Sensor, Mmtei: ❑ Tank(Null\Iligh•Levcl Sensor. Model: ❑ Other(specify equipment type and model in Section Eon Page 2). ❑ Oder(specify equipment type and model in Section Eon Page 2). TankID- Tank iD, p In-Tank Gauging Probe. Modcl: 0 In•Tank Gauging Probe. Model: ❑ Annular Space or Vault Somor. Model: ❑ Annular Space or Vault Sensor. Model; ❑ Piping Sump\Trench Sensor(S). Model: ❑ Piping Sump\Trench Scruutr(s). Modcl: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: ❑ Mechanical Linc Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Lino Leak Detector. Model: ❑ Electronic Line l.euk Detector. Model: Cl Tank overfill\High•Lcvcl Scosm. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(speci fy equipment type and model in Section E on Page 2), Dispenser ID Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Contaimnent Sensor(s). Model; ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). p Dispenser Containment Float(s)and Chain(s). Dispenser ID Dispenser U) ❑ Dispenser Containment Sensor(a). Model: ❑ Dispenser Comainmcntsensor(i). Model. ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispcnscr Containment Float(s)and Chain(s). Dispenser ID Dispenser ID ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s), Model: ❑ Shear Vaivc(s). p 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— 1 certify that the equipment identined in this document was inspected/serviced in accordance wlih the manufacturer's guidelines. Attached to this Certincaaon is information(e.g.manufactures'checklists)necessary 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 of the; (check all that apply). ❑ System set-up 9� Alarm history report Technician Name(printl: Y.. Signature: %—`— Mfg.Cert.#.: R1M_- ICC# JaZ w( License. No.: 485184 Phone No.: 408)9 '1-2445 Testing Company Name: SSS Testing Company Address: 680 Quinn Ave., San Jose,CA 95112 Date of Testing/Servicing: 1 v