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Monitoring System Equipment Certification For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 6.7, Health and Safely 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 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 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: VIR TLS-350 Date of Testing/Servicing: 6116110 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID•01-Regu Tank ID: 02-Prem 1% In-Tank Gauging Probe. Model: VR u7390-109 ()j In-Tank Gauging Probe. Model: VR 8.,17390-109 IN Annular Space or Vault Sensor. Model: VR 79,1390460 IN Annular Space or Vault Sensor. Model: VR 794390460 IN Piping Sump\Trench Sensor(s). Model: VR794390-209 IE Piping Sump\Trench Sensor(s). Model: VR 79,1380-208 CS Fill Sump Sensor(s). Model: VR 79,1380-208 (i( Fill Sump Sensor(s). Model: VR 794MO-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: (3 Electronic Line Leak Detector, Model: VR Sade.8484 13 Electronic Line Leak Detector, Model: VR sedes 8494 ❑ 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 on Page 2). Tank ID: 03-Diesel Tank ID: In-Tank Gauging Probe. Model: VR 847390-109 ❑ In-Tank Gauging Probe. Model: t% Annular Space or Vault Sensor. Model: VR794390460 ❑ Annular Space or Vault Sensor. Model: (% Piping Sump\Trench Sensor(s). Model: VR 794390-208 ❑ Piping Sump\Trench Sensor(s). Model: fg Fill Sump Sensor(s). Model: VR 794380.209 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Va sada•9ae4 ❑ Electronic Line Leak 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 on Page 2). Dispenser ID: 01-02 Dispenser ID: 03.04 Ig Dispenser Containment Sensor(a). Model: VR79t390-209 2 Dispenser Containment Sensor(s). Model: VR79438a-208 gj Shear Valve(s). IN Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05A6 Dispenser ID: 07-08 pj Dispenser Containment Sensor(s). Model: VR 79,180.208 IN Dispenser Containment Sensor(a). Model: VR 796380.208 fE Shear Valve(s). 13 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID; 09.10 Dispenser IDI 11-12 13 Dispenser Containment Sensor(a). Model: VR 79A99-209 la Dispenser Containment Sensor(s). Model: VR 794MG-208 Shear Valve(s). [3 ShearValve(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. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verify that this information is eorrest and a Not 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 ❑ Alarm history report Technician Name(print): Randy Wilkerson Signature: // tlr- Mfg.Cert.#.: A32404 ICC# 5258560-UT License.No.: 485184 Testing Company Name: Service Station Systems PhoneNo.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose, CA 95112 Date of Testing/Servicing: 6/16/10