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IPTar9 K*3gY IONITORING SYSTEM CERTIFICATION fuse By All Jurisdictions Within the State of Califomia„./ Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16, Division 3 Title 23, California Code of Regulations This forth 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 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 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 Facility Contact Person: CHASE JIANNALONE Date of Testing/Service: 02/18/2003 Make/Model of Monitoring System: VEEDER ROOT TLO Work Order Number: 2225442 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank lD: TK1 TanklD: TK2 X In-Tank Gauging Probe. Model: MAG PROBE X In-Tank Gauging Probe. Model: MAG PROBE X Annular Space or Vault Sensor. Model: FLOAT SENSOR Annular Space or Vault Sensor. Model: FLOAT SENSOR X Piping Sumprfrench Sensor(s). Model: FLOAT SENSOR Piping Sump/Trench Sensor(s). Model: FLOAT SENSOR X Fin Sump Sensor(s). Model: FLOAT SENSOR Fill Sump Sensor(s). Model: FLOAT SENSOR Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: PLLD X Electronic Line Leak Detector. Model: PLLD Tank Ovefill/High-Level Sensor. Model: Tank OverfilUHigh-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Others ci ( pe fy equipment type and model in Section E on page 2). Tank ID: Tank ID: X In-Tank Gauging Probe. Model: MAG PROBE In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: FLOAT SENSOR Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: F;OAT SENSOR Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model: FLOAT SENSOR Fill Sump Sensor(s). 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(specify,equipment type and model in Section E on page 2). Ispenser : 1/2 Dispenser ID: 7/8 71 Dispenser Containment Sensor(s) Model: FLOAT SENSOR X Dispenser Containment Sensors) Model FLOAT SENSOR X❑Shear Valve(s). X Shear Valve(s) 0 Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3/4 Dispenser ID: 9/10 FX-1 Dispenser Containment Sensor(s) Model:FLOAT SENSOR Dispenser Containment Sensor(s). Model:FLOAT SENSOR Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 DispenserlD: 11/12 ❑X Dispenser Containment Sensor(s) Model: FLOAT SENSOR X Dispenser Containment Sensor(s). Model:FLOAT SENSOR FXJ Shear Valve(s). X Shear Valve(s). EJDispenser Containment Floats)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 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): System set-up report; Alarm history report X❑ PRINTED NAME:JOHN R.SMYTH SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01