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MONITPIUNG SYSTEM CERTIFY' \TION ry/se By All Jurisdictions Within the State of Califomre,./ 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. If more than one monitoring system control panel is installed at the facility,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 forth must be provided to the tank system ovmer/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: SAFEWAY INC.. 1769 City: STOCKTON CA Zip:95204 Site Address: 2808 COUNTRY CLUB BLVD.. Contact Phone No: 467-2068 OFF 1-5 Date of Testing/Service: 01/15/2004 Facility Contact Person: CHASE JIANNALONE Make/Model of Monitoring System:TLS350 Work Order Number: 2229673 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced TanklD: 1 TanklD: 2 X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 460 Annular Space or Vault Sensor. Model: 460 X Piping Sump/Trench Sensor(s). Model: 352 Piping Sump/Trench Sensor(s). Model: 352 �( Fill Sump Sensor(s). Model: 352 352 Fill Sump Sensor($). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: PLLD X Electronic Line Leak Detector. Model: PLLD Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). TanklD: 3 TanklD: X In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 460 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 352 Piping Sump/Trench Sensor(s). Model: X1 Fill Sump Sensor(s). Model: 352 Fill Sump Sensoria). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: PLLD Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Other awdy equipment type and model in Section E on page 2). Dispenser 1/2 Dispenser ID: 3/4 O Dispenser Containment Sensor(s) Model: 322 X Dispenser Containment Sensor(s) Model:322 X❑Shear Valve(s). X Shear Valves) Dispenser Containment Float(s)and Chain(s). 7 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 7 Dispenser Containment Sensors) Model:322 Dispenser Containment Sensor(s). Model:322 X❑ Shear Valve(s). 71 Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 ❑X Dispenser Containment Sensor(s) Model: 322 X Dispenser Containment Sensor(s). Model:322 ❑X Shear Valve(s). X Shear Velvets). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float($)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 manufacturers'guidelines. Attached to this certification is information(e.g manufacturers'checklists)necessary to verify that this information is correct. and a Site 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): M System set-up X❑Alarm history report Technician Name(print): RHOME DESBIENS Signature: Certification No.: 3083 License.No.: Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8900 Shoal Creek,Bldg.200 Austin,TX 78757 Date of Testing/Servicing: 01/15/2004 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01