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AUG -15-2006 13:59 Service Station Systems 4oe 938 8688 P.02 Monitoritt System Equipment ertification For Use By All Jurisdictions Within The Stare of California 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. A separate certification or report must be prepared for each monitorings stem 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 system within 30 days of test date. A. General Information Facility Name: Safeway 2600 Bldg. No.: Site Address: 1804 West 11Th. Street @ Corral Hallow City: Tracy, CA Zip: 95376 - Facility Contact Person: Nathan Make/Model of Monitoring System: WR TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced; Contact Phone No.: (209) 830-2950 Date of Testing/Servicing: 8/3/06 Tank II). 01-Regu __ Tank ID: 02 -Plus N In - Tank Gauging Probe. Modcl: VR 947390-109 Qg In - Tank Gauging Probe. Model: VR 847380-109 19 Annular Space or Vault Sensor. Model: VR 794390420 ❑ Annular Space or Vault Sensor. Model: Now 99 Piping Sump 1 Trench Sensor (s), Model: VR 784380-268 lig Piping Sump 1 Trench Scncor (s). Model: VR 7"s90420 IQ Fill Sump Sensor (s). Model: VR 794380-208 95 Fill Sump Sensor (s). Model: VR 794380-208 13 Mechanical Line Leak Detector, Model: None ❑ Mechanicat Line Leak Detector, Model: None a Electronic Line Leak Detector. Model: VR Series 8484 I9 F-loctronic Line Leak Detector. Model: VH Sarin 8484 99 Tank Overfill 1 High -Level Sensor. Model: VR 790091.001 I9 Tank Overfill 1 High -Level Sensor. !Model: VR 750087-001 0 Other ( specify equipment type and model in Section E en Page 2). ❑ Other ( specify equipment type and model in Section E on Page 2). Tank ID. 03 -Prem Tank ID• p In - Tank Gauging Probe. Model; VR 847390-169 to In - Tank Gauging Probe. Model: a Annular Space or Vault Sensor. Model; VR 794390.420 ❑ Annular Space or Vault Sensor, Model: 3 Piping Sump \ Trench Sensor (s). Model; VR 794180208 ❑ Piping Sump 1 Trench Sensor (s). Model: ® Fill Sump Sensor (s). Model: VR 794380-208 ❑ Fill Sump Sensor (s). Model: [] Mechanical Line Leak Detector. Model: None ❑Mechanical Line Leak Dct=or. Model: ® Electronic Line Leak Detector. Model: VR series 8484 ❑ Electronic Line Leak Detector. Model: ® Tank Overfill 1 High -Level Sensor. Model: VR 790091.001 [p Tank Overfill \ Hil h -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ Other ( specify equipment typo and model in Section F on Page 2). ID: 01-02 Dispenser Iii; 03-04 r Containment Sensor (s). ED lVlodcL vR 794390 zoe 9q Dispenser Containment Scncor (s). Model: VR 794384208 lve (s). 29 Shear Valvc (s).r Containment Float (s) and Chain (s). ❑ Disponset• Containment Float (s) and Chain (s). Dispenser ID: 05-06 _ Dispenser ID; 07-08 S Dispenser Containment Sensor (s). Model VR 7943110-203 99 Dispenser Containment Sensor (s). Model: VR 79.4390-208 0 Shear Valve (s)- 99 Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). 0 'Dispenser Containment Float (s) and Chain (s). Dispenser 11. 08-10 Dispenser ID; 11-12 g) Dispenser Containment Sensor (s). Model: VR 794380-208 99 Dispenser Containment Sensor (s). Model: VR 794380208 ® Shear Valve (s). N Shear Valve (s). ❑ Dispenser Containment Float (s) 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 manufacturer's guidelines. Attached to this Certification is information (e.g, manufactures' 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 reports, I have also attached a copy of the; ( check all that apply): 2 System sct-up K Alarm history report Technician Natne (print): Randy Wilkerson Signature: aldd - Mfg. Cert.#.: A32404 ICC# 5258560 -UT License_ No.: 485184 Testing Company Name: Sere. Sta. Sys. Phone No.: (408) 971-2445 Site Address: 1804 West 11Th. Street @ Corral Hallow Date of Testing/Servicing: 8/3/06