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06/20/2003 09:47 40897103 SSS INC PAGE 02 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7, Health and Safety Code; Chapler 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 mim Si ibmit a copy of this form to the local agcpcy regulating VST systems withtn 30 days of test date. A. General Information Facility Name: SafewayBld No.: 8• Site Address: 2808 Country Club Blvd. Ciry:.Stockton v Zip:95204 Facility Contact Person: Sharon Lovell Contact Phone No.: (209)461-5555 Make/Mndel of Monitoring System: Veedcr Root TLS 350 Date of'resting/Servicing: 5.23-2003 B. Inventory of Equipment Tested/Certified Check the aporapriate taxes to indicate s ecirmc-equignient ins ected/serviced: Tank ID: REGULAR Tank 11) ❑ ln.Tank Gauging Probe. Model. Q in=lank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model- Q Piping Sump/Trench Sensor(s). Model: Q Piping Sump/Trench Sensor(s). Model: M Fill Sump Sensor(s). Mudcl:794380-352 U Fill Sump Sensor(s). Model: ❑ Mechanical Linc Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: Q Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Leve]Sensor. Model: Q Other(specify equipment t e and model in Section E on Page 2). O Other(specify equipment and model in Section E on page 2). Tank ID: Tank 1D- 0 In-Tank Gauging Probe. Model: Q In-Tank Gauging Probe. Model: Q Annular Space or Vault Sensor, Model: Q Annular Space or Vault Sensor. Model ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Tranch Sensor(s). Model: U Fill Sump Sensor(s). Model: Q Fill Sump Sensor(s), Model: Q Mechanical Line Leak Detector, Model: U Mechanical Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: Q Electronic Linc Leak Detector, mlydel: Q Tank Overfill/High-Level Sensor. Model. ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify c ui ment t e and model in Section E on Page 2). _P_O1rhqqsPecifY N ui ment type and model in Section E on page 2), Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Q Dispenser Containment Sensor(s). Model: M Shear Valve(s). O Shear Vaive(s). Q Dis nscr Cuurainrnent Ploar(s)and Chain(s), ❑ Dispenser Containment Float(s)and Chain(s). Dispenser 10: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispencer Containment Scnsor(s). Muriel: Q Shear Valve(s). ❑ Shear Valvc(s)- ispenser Containment Floats and Chain(s). Q Dispenser Containment Floats and Chain(s). Dispenser 1D- Dispenser LU; Q Dispenser Containment Sensor(s). Model: Q Dispenser Containment Sensor(s). Model: Q Shear Valve(s). ❑ Shear Valve(s). ODi mrar Containment Floats)wxi Chaiu(s). U Dis nscr Containment Floa 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 manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers, 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 reporter I have at" attached a copy urthe report; (ekecti au tliat apply): U System set-up U Alarm history report Technician Name(print):Tim Riddle Signature;On file @ Service Station Systems Inc Certification No.: 567679605 License.No.:485184 Testing Company Ni mc: Service Station Systems Inc Phone No.: (408)971-2445 Site Address: 2808 Country Club Blvd Date of Testing/Servicing:5-23-2003