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RECEIVED Monitoring System Equipment Certificatilaw 17 2017 For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 6.7, Health and Safety Cade; Chapter 16, Division 3, Title 23, California Code oQWk4 bniiiclV I AL ��y D-?AATMENT This form must be used to document testing and servicing of monitoring equipment. A separate certification muss be prepared for each monitoring system control12anel 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 Site Address: 6425 N. Pacific Ave. Bldg. No.: City: Stockton, CA Zip: 95207 - Facility Contact Person: Caroline Contact Phone No.: (209) 472-8600 MakeModel of Monitoring System: VR TLS -350 Date of Testing/Servicing: 1/19/17 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 01-Rogu Tank ID: 02 -Prem 9 In- Tank Gauging Probe. Model: VR 947390-109 11 In- Tank Gauging Probe. Model: VR947390-109 ® Annular Space or Vault Sensor. Model: VR 794390460 2 Annular Space or Vault Sensor. Model- VR 794390.460 Z Piping Sump l Trench Sensor (a), Model: VR 790360-209 ® Piping Sump\ Trench Sensor (s). Model: VR 794380-208 ® Fill Sump Sensor (3). Model: VR 794360.209 0 Fill Sump Sensor (s). Model: VR 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR S.A. e4e4 11 Electronic Line Leak Detector. Model: VR Series SIM ® Tank Overfill \ High -Level Sensor. Model: VR790991-001 ® Tank Overfill \ High -Level Sensor. Model: VR790091401 ❑ Other ( specify equipment rypc and model in Section E on Page 2). ❑ Other ( specify equipment type and model in Section E on Page 2). Tank II)' 03 -Diesel Tank ID: ® In- Tank Gauging Probe. Model: VR 847380-109 ❑ In- Tank Gauging Probe. Madel: ® Annular Space or Vault Sensor. Madel: VR7M39ad60 ❑ Annular Space or Vault Sensor. Madel: ® Piping Sump V Trench Sensor (s). Model: VR79IL380.408 ❑ Piping Sump\Trench Sensor(s). Model: ® Fill Sump Sensor (s). Model: VR79USO.208 ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: N Electronic Line Leak Detector. Model: VR Sed. 9484 ❑ Electronic Line Leak Detector. Model: ® 'a OveKlt \high -Level Sensor. Model: VR 790091401 ❑ Tank Overfill \ High -Level Sensor. Mode]: ❑ 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 791380.208 ® Dispenser Containment Sensor (s). Model: VR 784380.209 ® Shear Valve (s). N 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 (a) Model: VR 794380-200 01 Dispenser Containment Sensor (s). Model: VR 794380-208 11 Shear Valve (s). ® Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 08-10 Dispenser ID: 11-72 ® Dispenser Containment Sensor (s). Model: VR794330.208 ® Dispenser Containment Sensor (s). Model: VR7943M208 00 Shear Valve (s). ® 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 (0-g. manufactures' checklists ) necessary to verify that this information is correct and a Piot 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 Maiappfy): ® System set-up ® Alarm history report taw_ Technician Name (print): Brian McPheely Signature: Mfg. Cert.#.: B36745 ICC# 8394903 -UT License. No.: 485184 Testing Company Name: Seryice Station Systems Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 1119/17