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09/18/2002 09:46 120936F1543 TANKNOLOGY PAGE 09/11 MONITORING SYSTEM CERTIFICATION �d Illp Tbnkno ogy For Use By All Jurisdictions Within the State of California Authority Cited;Chapter 6,7,Health and Safety Code;Chapter 18,Division 3 Tiffs 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If morn than one monitoring system control panel Is installod at the feeillty,a separate certificaii9n or report must be oreoared fpr each monitoring aystem 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 tho local agency regulating UST systems within 30 days of test date, A.General Information Facility Name: SAFEWAY 2600 City: TRACY CA Zip:95376 Site Address: 1987 WEST 11TH Contact Phone No!000-0000 Date of Testing/Service: 09/16/2002 Facility Contact Person: MANAGER Make/Model of Monitoring System: VR TLS35OR Work Order Number. 2223782 8.Inventory of Equipment Tested/Cer ifled Check the appropriate boxes to indicate specific equipment Inspected/serviced Tank ID: REGULAR Tank 10: PLUS X In-Tank Gauging Probe. Model: 847380.107 X In-Tank Gauging Probe. Model: 847380107 X Annular Space or Vault Sonsor. Model: 794390._420 Annular Space or Vault Sensor. Model: 794390.420 71 Piping Sump/Trench Sansor(s), Model: 784380-208 Piping Sump/Tranch Sensor(s), Model: 794380.208 X Flit Sump Sonsor(s). Model; 744300-208 FIII Sump Sensor(s). Model: 794380-208 Mechanical Line Leak Detector, Model: Mechanical Una Leak Detector. Model: Electronic Lino Leak Detector. Model: PLLD(2) X Electronic Lino Leak Detector. Model. PLLD 71 Tank Overfill/htlgh-Level Sensor, Model: KLAXON/LAMP(ATG) X Tank OverfilVHigh-Level Sensor, Model; KLAXON/LAMP(ATC) Other(specify oqulpment type and model In Section E on page 2). Othor(specify equipment type and model In Section E on page 2). Tank 10: TanK ID: X in-Tank Gauglnq Probe. Model: 947380-107 In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 794390-420 Annular Space or Vault Sensor. Model: X Piping Sump/Tronch Sensor(s). Model: 794380-208 Piping Sump/Treneh Sansoga). Model: X Fill Sump Sensor(s), Modol: 794380.208 FIII Sump Sensor(s). Model: Mechanical Una Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector, Model: PLLD Eioctronlc Line Leak Detector. Model: X Tank Ovorfnl/Hlgh-Leval Sensor. Model: KLAXON/LAMP(ATG) 7Tank Overflll/High•Lavat Sensor. Modol: Other(Specify equipment typo and model in Section E on page 2). 7Other(Speclfy equipment type and model in Section E on page 2). Dispenser : 1/2 Dispenser ID: 7/8_ Dispenser Containment Sensors) Model 784380-208 X Dispenser Containment Sensors) Model:794380208 X Shear Valve(s). X Shear Valve(s) Ej Dispenser Containment Float(S)and Chain(s), Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3/4 Dispenser ID: 9110 X 1 Dispenser Containment Sensoria) Model:794380.208 Dispenser Containment Sensor(S). Model:794380208 XT ShearValve(s), Shearvalve(s). Dispenser Containment Float(s)and Chaln(s). Dispenser Containment Float(s)and Chaln(s). Dispenser ID: 5/6 DispenserlD: 11/12 M Dispenser Containment Sensors) Model:794380.208 Dispenser Containment Sensor(s). Modol:13/14 OX Shear valve(s). X Shear Valve(s). Dispenser Containment Flost(s)and Chain(s), Disponsor Contalnment Float(s)and Chaln(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 Identlfled in this document was Inspected/serviced In accordance with the manufacturers'guidelines. Attached to this certlflcation 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: 7X Alarm history report XD PRINTED NAMENICHAEL T LEVESQUE SIGNATURE: COMPANY: Tanknoloav PHONE NO: (800)800-4633 page 1 of 3 Based on CA farm dated 03%01