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PP %ankncdoc 10NITORING SYSTEM CERTIFICATION <br />I se By All Jurisdictions Within the State of Californi, <br />Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3 Title 23, California Code of Regulations <br />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 <br />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 <br />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. <br />A. General Information <br />Facility Name: SAFEWAY 2600 <br />Site Address: 1987 WEST 11TH <br />Facility Contact Person: MANAGER <br />Make/Model of Monitoring System: VEEDER ROOT TLS <br />B. Inventory of Equipment Tested/Certified <br />City: TRACY CA Zip: 95376 <br />Contact Phone No: 830-2950 <br />Date of Testing/Service: 09/08/2003 <br />Work Order Number: 2228368 <br />Check the appropriate boxes to indicate specific equipment inspected/serviced <br />Tank ID: SUPER <br />Tank ID: PLUS <br />X <br />In -Tank Gauging Probe. <br />Model: MAG 1 <br />Q <br />In -Tank Gauging Probe. <br />Model: MAG 1 <br />X <br />Annular Space or Vault Sensor. <br />Model: 794390-420 <br />El <br />Annular Space or Vault Sensor. <br />Model: 794390-420 <br />71 <br />Piping Sump/Trench Sensor(s). <br />Model: 794380-208E <br />Piping Sump/Trench Sensor(s). <br />Model: 794380-208 <br />X <br />Fill Sump Sensor(s). <br />Model: 794380-208 <br />® <br />Fill Sump Sensor(s). <br />Model: 794380-208 <br />Mechanical Line Leak Detector. <br />Model: <br />❑ <br />Mechanical Line Leak Detector. <br />Model: <br />Electronic Line Leak Detector. <br />Model: PLLD <br />❑X <br />Electronic Line Leak Detector. <br />Model: PLLD <br />Tank Overfill/High-Level Sensor. <br />Model: <br />❑ <br />Tank Overfill/High-Level Sensor. <br />Model: <br />Other (specify equipment type and <br />model in Section E on page 2). <br />Other (specify equipment type and model in Section E on page 2). <br />Tank ID: REGULAR <br />Tank ID: <br />X <br />In -Tank Gauging Probe. <br />Model: MAG 1 <br />In -Tank Gauging Probe. <br />Model: <br />X <br />Annular Space or Vault Sensor. <br />Model: 794390-420 <br />Annular Space or Vault Sensor. <br />Model: <br />X <br />Piping Sump/Trench Sensor(s). <br />Model: 794380-208 <br />Piping Sump/Trench Sensor(s). <br />Model: <br />X <br />Fill Sump Sensor(s). <br />Model: 794380-208 <br />Fill Sump Sensor(s). <br />Model: <br />Mechanical Line Leak Detector. <br />Model: <br />Mechanical Line Leak Detector. <br />Model: <br />X <br />Electronic Line Leak Detector. <br />Model: PLLD <br />Electronic Line Leak Detector. <br />Model: <br />Tank Overfill/High-Level Sensor. <br />Model: <br />Tank Overfill/High-Level Sensor. <br />Model: <br />Other (specify equipment type and <br />model in Section E on page 2). <br />❑ <br />Other (specify equipment type and model in Section E on page 2). <br />Dispenser : 1-2 <br />Dispenser ID: 3-4 <br />X❑ <br />Dispenser Containment Sensor(s) <br />Model: 794380-208 <br />FX� <br />Dispenser Containment Sensor(s) <br />Model: 794380-208 <br />X❑ <br />Shear Valve(s). <br />Shear Valve(s) <br />❑ <br />Dispenser Containment Float(s) and Chain(s). <br />Dispenser Containment Float(s) and Chain(s). <br />Dispenser ID: 5-6 <br />Dispenser ID: 7-8 <br />X❑ <br />Dispenser Containment Sensor(s) <br />Model: 794380-208 <br />Dispenser Containment Sensor(s). <br />Model: 794380-208 <br />X❑ <br />Shear Valve(s). <br />Shear Valve(s). <br />Dispenser Containment Float(s) and <br />Chain(s). <br />Dispenser Containment Float(s) and Chain(s). <br />Dispenser ID: 9-10 <br />Dispenser ID: 11-12 <br />❑X <br />Dispenser Containment Sensor(s) <br />Model: 794380-208 <br />X <br />Dispenser Containment Sensor(s). <br />Model: 794380-208 <br />F] <br />Shear Valve(s). <br />FX� <br />Shear Valve(s). <br />❑ <br />Dispenser Containment Float(s) and Chain(s). <br />E1 <br />Dispenser Containment Float(s) and Chain(s). <br />" If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. <br />C. Certification <br />I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. <br />Attached to this certification is information (e.g manufacturers' checklists) necessary to verify that this information is correct. <br />and a Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached <br />a copy of the (Check all that apply): System set-up report; ❑ Alarm history report X❑ <br />PRINTED NAME. <br />•ANEIL CHAND SIGNATURE: <br />)-it�_v <br />COMPANY: Tanknology PHONE NO: (800) 800-4633 <br />page 1 of 3 Based on CA form dated 03/01 <br />