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AUG -15-2006 14:00 Service Station Systems 408 938 8888 P.03 Monitorixt System Equipment . ,ertification For Use By All Jurisdictions Within The State of California Authority Cited- Chapter 6.7, Health and Safety Code; Chapter 76, 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 natty 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 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 Contact Phone No.: (209) 830.2950 Make/Model of Monitoring System: WR TLS -350 Date of Testing/Servicing: 8/3106 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspceted/servieed: Tank ID: Tank ID; ❑ in - Tank Gauging Probe. Model: Q In - Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor, Model: p Annular Space or Vault Sensor. Model: ❑ Piping Sump 1 Trench Sensor (s). Model: p Piping Sump 1 Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s)_ Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical line l-cak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Lino I.,cak Detector, Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill 1 High-Lcvcl Scnsor. Model: ❑ Other ( specify equipment type and model in Section I. on Page 2). ❑. Other ( specify equipment type and model in Section I- on Page 2)_ Tank ID; Tank ID• ❑ In - Tank Gauging Probe. Model ❑ In - Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor_ Model: p Annular Space or Vault Sensor. Model: ❑ Piping Sump 1 Trench Sensor (s). Modcl: ❑ Piping Sump 1 Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Mndcl: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 0 Electronic Lino Leak Detector. Model: C3Electronic lane Leak DCtt%:tor. Model: 13Tank Overfill \ High -Level Sensor. Modcl: ❑ Tank Overfill 1 High-l..ovcl 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). Dispenser ID- 13-14 Dispenser ID: 75-t6 a Dispenscr Contaimr=t Sensor (s). Model: Vit 794340-208 N Dispenser Containment Sensor (a). Model: VR 794430-20s Cl Shear Valve (s)_ H Shear Valve (s), 0 Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID. 17.18 Dispenser TD: 19-24 N Dispenser Containment Sonsor (s)_ Model: VA 794380.208 a Dispenser Containment Sensor (s). Model: VR794380-208 Q9 Shear Valve (s). Ig Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: _ Dispenser ID• Cl Dispenser Containment Sensor (s). Model: ❑ Dispenscr Containment Sensor (s), Model: ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenscr 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): ® System set-up 0 Alarm history report Technician Name (print): Dandy Wilkerson Signature:�.- Mfg. Cert.#.: A32404 ICC# 5258560 -UT License. No.: 485184 Testing Company Name: Serv. Sta. Sys. Phone No.: (408) 971-2445 Site Address: 1804 West 11Th. Street @ Corral Hallow Date of Testing/Servicing: 813/06