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SEP-03-2008 08:54 Service Station Systems 408 938 8888 P.04 Monitorio* System Equipment ;ertification For Use By All Jurisdictions Within The State of California .Authority Cited: Chapter 6.i, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regtilations 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 panel by the technician who performs the work. A copy of this forth 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 2 Corral Hallow City: Tracy, CA Zip: 95376- Facility Contact Person. Manager Contact Phone No.: (2091830-2950 Make/Model of Monitoring System: V/R TLS-350 Date of Testing=Servicing: 814108 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID• Tank ID; ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model; ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor, Model; ❑ Piping Sump 1 Trench Sensor(s). Model: p Piping Sump\Trench Sensor(s). Modcl: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Modcl, ❑ Mechanical Line Lcak Detector. Model; ❑ Electronic Line Leal:Detector. Model: p Electronic Line Leak Detector. Model: p Tank Overfill\High-Level Sensor. Model; ❑ Tank Overfill\High-Luvcl 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 l% Tank ID: ❑ in-Tank Gauging Probe. Model ❑ In-Tank Gauging Probe, Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s), Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Scnsor(s). Model ❑ Mechanical Linc Leak Detector. Model: ❑ Mechanical Line Leak Detector, Ivtodd: ❑ Electronic Line Leak Detector. Modcl; ❑ Electronic Line Leak Detector. Model; ❑ Tank Overfill\High-Level Sensor. Modcl ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Othcr(specify cquipmcnt type and model in Section E on Page 2). Dispenser ID: 13-14 Dispenser ID- 15-16 la Dispenser Containment Sensor(s). Modcl: VR 794390QO9 �, Dispenser Containment Sensor(s). Model: VR 794390-208 11 Shear Valve(s). I[,S Shcar Valve(S), 0 Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). EDnser ID: 17-18 Dispenser ID- 19-20 nser Containment Sensor(S). Model: VR 794380-208 Dispenser Containment Sensor(s). Model: VR 794390.208 Valve(s). Id Shear Valvc(s). nser Containment Float(s)and Chain(s). ❑ Dispenser Containment Flout(s)and Chain(s). Dispenser ID; Dispenser Ill: _ ❑ Dispenser Containment Sensor(s). Ivlodcl; ❑ Dispenser Containment Scnsor(s). Model: ❑ Shear Valve(s). Cl Shear Valve(s). p Dispenstr Containment FIoat(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 eertifv 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'checklistq)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). ❑ Sysrem set-up ❑ Alarm history report Technician Name(print): Randy Wilkerson Signature: /�ZL4— 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/Servicing: 814108