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SEP-03-2008 08:54 Service Station Systems 408 '338 8888 P.03 Monitorit System Equipment certification For Use By All Jurisdictions Within The State of'California Authority Cued: 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 igonitor)ngs .tem 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 loom.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 @ Corral Hallow 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: 8/4/08 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:01-Regu _ _ Tank ID: 02-Plus 13 In-Tank Gauging Probe. Model: VR 847390-109 Qj In-Tank Gauging Probe. Model; VR 847390.109 Qj Annular Space or Vault Sensor. Model: VR 794390.420 Qj Annular Space or Vault Sensor. Model: VR 794390.820 EX Piping Sump\Trench Sensor(s). Model: VR 794m0-208 M Piping Sump\-french Sensor(s). Model: VR 794330-20e % Fill Sump Sensor(s). Madel: VR 794380-208 QI Fill Sump Sensor(s). Model: VR 794330-20e ❑ Mechanical Line Leak Detector. lvlodcl: Nano Q Mechanical Line Leak Detector. Modcl: None la Electronic bine teak Detector. Model: VR Sart es$484 fa F:Icctmnic Cine Leak Detector. Model: VR Sones 0484 ❑ Tank Overfill\Higli-Level Sensor. Model: none ❑ Tank Overfill\High-Level Sensor. Model: None Q Other(specify equipment type and model in Section E on 1'agc 2). ❑ Other(specify egeipment type and model in Section F on Pa,e 2). Tank ID• 03-Prem Tank ID• 1S in-Tank Gauging Probe. Model: VR 847390.109 ❑ in-Tank Gauging Probe. Model: 11 Annular Space or Vault Sensor. Model- Va 794390-420 ❑ Annular Space or Vault Sensor. Model: lg Piping Sump\'I'rcnch Sensor(s). Model VR 794380-200 (:l Piping Sump\ french Sensor(s). Model: [% Fill Sunip Sensor(s). Model: VR 794330-20e Q Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector, Model: None ❑ Mechanical Linc beak Detector. MudeL Electronic Line Leak Detector, Model; VR series 8484 ❑ Electronic Linc Leak Detector. Model: Q Tank Overfill\High-Level Sensor. Model; None Q Tank Overfill\High-Level Sensor, Model: Q Other(,specify equipment type and model in Section E on?ago 2). Q Other(specify equipment type and model in Section E on page 2). Dispenser TO: 01.02 Dispenser ID• 03-04 _ lg Dispenser Containment Sensor(s). Model: VR 794380.208 Qj Dispenser Containment Sensor(s), Modcl: VR 794380-808 QI Shear Valve(s). Qj Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). Q Dispenser Containment Float(s)and Chain(s). Dispenser TD: 05-06 _ Dispenser lll• 07-08 Qj Dispenser Containment Sensor(s). Model: VR 794380-208__ [XDispenser(:ontainment Sensor(s). Model: VR 794380.208 ,p ShearValve(s). iX Shear Valve(s). Q Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 09-10 Dispenser 1D- 11-12 - Qj Dispenser Containment Sensor(s). Model: VR 794s80-208 [X Dispenser Containment Sensor(s). ;Model; VR 794380.209 Qj She9r Valve(s). Ix Shcar Valve(s). p 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. Certifleation- 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 it 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(rll that apply): t] System set-up p Alarm history report Technician Name(print): Randy Wilkerson Signattue: I Mfg,Cert.#.: A32404 ICC# 5258560-UT License. No.: 485184 Testing Company Name: Serv. Sta. Sys. Phone No.: 408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose CA 95112 Date of Testing/Servicinr: 814108