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REGEIVEL Monitoring System Equipment Certification FEB 19 2016 For Use By All Jurisdictions Within The State of California C Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code ofR WRONMENTAL 14%I TU r=P4RTh/1FhIT 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 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: 6425 N. Pacific Ave. City: Stockton, CA Zip: 95207 - Facility Contact Person: Manager Contact Phone No.: (209) 472-8600 Make/Model of Monitoring System: VR TLS -350 Date of Testing/Servicing: 1/20116 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 01-Rf190 Tank ID• 02 -Prem ® In- Tank Gauging Probe. Model: VR 947300.109 11 In- Tank Gauging Probe. Model: VR 847390,109, ® Annular Space or Vault Sensor. Model: VR 7909MSO ® Annular Space or Vault Sensor. Model: VR 79u9,0.4e0 9 Piping Sump\ Trench Sensor (a), Model- VR 7MOD-208 ® Piping Sump Trench Sensor (a), Model: VR 794380,208 ® Fill Sump Sensor (a), Model: VR 79,13110,2011 ® Fill Sump Sensor (a). Model: VR 7%38w08 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR soden 8480, ® Electronic Line Leak Detector. Model: VR series 9884 01 Tank Overfill \ High -Level Sensor. Model: VR 7 90 0 91-0 01 ® Tank Overfill \ High -Level Sensor. Model: vR 790091.001 19 Other ( specify equipment type and model in Section G on Page 2). ® Other ( specify equipment type it model in Section E on Page 2). Tank ID: 03 -Diesel Tank ID: ® In- Tank Gauging Probe. Model: VR847320-109 ❑ In- Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 794300-1i, ❑ An polar Space or Vault Sensor. Model: ® Piping Sump\ Trench Sensor (s). Model: vR 794380.208 ❑ Piping Sump\ Trench Sensor (s). Model: ® Fill Sump Sensor (a). Model: VR 794380-2011 ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR Series NU ❑ Electronic Line Leak Detector. Model: - • Tank Overfill i High -Level Sensor. Model: IM790091-001 ❑ 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). Dispenser ID: 01-02 Dispenser ID: 03.04 ® Dispenser Containment Sensor (s). Model: VR 798380,209 ® Dispenser Containment Sensor (a). Model: VR 7943aa20e ® Shear valve (s). 0 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 794380.208 9 Dispenser Containment Sensor (s). Model: VR 798380,20/1 ® Shear Valve (s). R Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 16.10 Dispenser ID: 11-12 no Dispenser Containment Sensor (s). Model: VR794380.2011 ® Dispenser Containment Sensor (a). Model: VR79439,a209 ® 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 (e.g. manufactures' checklists ) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. Far any equipment capable of generating such reports, I have also attached a copy of the; (check all that apply): ❑ System set-up ❑ Alarm history yrreport Technician Name (print): Kris Bell Signature: Mfg. Cert.#.: B33709 ICC# 5297793 -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: 1120116