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Monitoring System Equipment Certification For Use By All Jurisdictions Within The State of'Cal fornia Authority Cited:Chapter 6.7,Health and Safety Code; Chapter/6,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 monitoring system control parcel 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 Bldg.No.: Site Address: 1804 West 11Th. Street City: Tracy, CA Zip: 95376- Facility Contact Person: Manager Contact Phone No.:_(209)830-2950 Make/Model of Monitoring System: V/R TLS-350 Date of Testing/Servicing: 6/5/12 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank TD:01-Regu Tank 11)• 02-Prem ® In-Tank Gauging Probe. Model: VR 847390-109 ® In-Tank Gauging Probe, Model: VR 847390-109 Annular Space or Vault Sensor. Model: VR 794390460 ® Annular Space or Vault Sensor. Model: VR 794390-460 Piping Sump\Trench Sensor(s), Model: vR 794380-208 ® Piping Sump\Trench Sensor(s). Model: VR 794380-208 ® Fill Sump Sensor(s). Model: VR 794380-208 ® Fill Sump Sensor(s). Model; VR 794380.208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR series 8484 ® Electronic Line Leak Detector. Model: VR Series 8484 ❑ Tank Overfill\High-Level Sensor. Model: p 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). Tank 1R; 03-Diesel Tank Il?: ® In-Tank Gauging Probe. Model: VR 847390-109 ❑ In-Tank Gauging Probe. Model: all Annular Space or Vault Sensor, Model: VR 794390-460 ❑ Annular Space or Vault Sensor. Model: I@ Piping Sump\Trench Sensor(s). Model: VR 794380-208 ❑ Piping Sump\Trench Sensor(s). Model: 3 Fill Sump Sensor(a). Model; VR 794390-208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Linc Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector, Model: VR series 8484 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: Cl 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• 01-02 Dispenser ID., 03-04 ® Dispenser Containment Sensor(s). Model: VR 794380.208 ® Dispenser Containment Sensor(s), Model: VR 794380-208 IV Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05-06 Dispenser ID- 07-08 ® Dispenser Containment Sensor(s). Model: VR 794380.208 Dispenser Containment Sensor(s). Model: VR 794380-208 ® Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). E r ID- 09-10 Dispenser ID• 11-12 er Containment Sensor(s). Model: VR 794380-208 ® Dispenser Containment Sensor(s). Model: VR 794360.208 alve(s). ® Shear Valve(s). er 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 - 1 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 ❑ Alarm history report Technician Name(print): Randy Wilkerson Signature: LLIV� Mfg.Cert./#.: A32404 ICC# 5258560-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose,CA 95112 Date of Testing/Servicing: 6/5/12