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R CEI VEV Monitoring System Equipment Certiflcat'O202015 For Use By All Jurisdictions Within The .Stale of California �y Authority Cited: Chapter 6.7, Health and Safely Code: Chapter 16, Division 3, Tale 23, California SN"'VIY� � This form must be used to document testing and servicing of monitoring equipment. A separate certification or rega. otyi6�'ENIIAL 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: 1122/15 B. Inventory of Equipment Tested/Certified .- t,..... ,. c,,..m, n..,inment iasnecmd/serelmd: If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facilaN C. Certification - [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, 1 have also attached a copy ofthe: (cheek all that spplyl: ❑ Systemset-up ❑Q Alarm history report Technician Name (print)• Randy Wilkerson Signature: LLL 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 96112 Date of Testing/Servicing: 1/22/15 Tank ID•01-Regu Tank ID• 02 -Prem ® In- Tank Gauging Probe. Model. VR647390a109 M In- Tank Gauging Probe Model: VR &V390-109 ® Annular Space or Vault Sensor Mode;: VR 7943110460 ® Annular Space or Vault Sensor. Model VR 79439x460 ® Piping Sump\ Trench Sensor (a). Model: VR 794380.208 ® Piping Sump � Trench Sensor (a) Model. VR 794390.208 ® Fill Sump Sensor (a). Model. VR7%38a208 00 Fill Sump Sensor is). Model: VR 784360409 ❑ Mechanical Line Leak Detector. Madel: ❑ Mechanical Line Leak Detector Model: M Electronic Line Leak Detector. Model VR Sari,. 114114 ® Electronic Line Leak Detector. Model: VR Senn 8484 ❑ Tank Overfill l High-level Sensor. Model: VR790091.001 ❑ Tank Oveifll\ High -Level Sensor. Model: VR 7WN14M ❑ 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 Uh 03 -Diesel Tank TD- ® In -'rank Gauging PCObu. Model: VR 847390-109 ❑ In - Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 794390460 ❑ Annular Space or Vault Sensor. Model. ® Piping Sump\ Trench Sensor (s). Model. VR 7119380208 ❑ Piping Sump Trench Sensor (s). Model: ® Fill Sump Sensor (s). Madel: VR 7343110-2011 ❑ Fill Sump Sensor (s) Model; ❑ Mechanical Line Leak Detector. Model. ❑ Mechanical Line Leak Detector. Model 9 Electronic Line Leak Detector, Model: VR 6adn 8434 ❑ Electronic Line Leak Delecton Model. ❑ Tank Overfill \ High -Level Sensor. Madel: VR 79009 l ❑ Tank Overfill \ High -Level Sensor Model: ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ Other ( specify equipment type tend model in Section E on Page 2). Disppenser ID- 01.02 Dispenser ID: 03.04 It Dispenser Containment Sensor (a). Model: VR 79438x208 It Dispenser Containment Sensor Is). Model VR 794080-20e ® Shear Valve (s). ® Shear Valve (s) ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Contsmment Float (s) and Cham (s) Dispenser ID: 06.06 Dispenser IDS 07.08 _ 0 Dispenser Containment Sensor (s) Madel VR7N38a4o6 CO Dispenser Containment Senior (a). Model: VR 794"x2011 ® Shear Valve (s). M Shear Valve (s). ❑ Dispenser Containment Floats) and Chain (s). ❑ Dispenser Containment Float (a) and Chain (a), Dispenser In, 08.10 Dispenser ID- 11.12 0 Dispenser Containment Sensor (s) Model. VR794380,20e ® Dispenser Containment Senior (s). Model' VR 794080408 R Shear Valve (s). ® Shcar Valve (s). Cl Dispenser Containment Float (s) and Chain (s) Cl Dispenser Containment Float (s) and Chain (sl If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facilaN C. Certification - [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, 1 have also attached a copy ofthe: (cheek all that spplyl: ❑ Systemset-up ❑Q Alarm history report Technician Name (print)• Randy Wilkerson Signature: LLL 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 96112 Date of Testing/Servicing: 1/22/15