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Monitoring System Equipment Certific ECEIVED For Use By All Jurisdictions Within The State ofC'aljfornia Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16. Division 3, Title 23, California Code of Re02c Q 2915 This form must be used to document testing and servicing of monitoring equipment. A t certification ��A prepared for each monitoring system control panel by the technician who performs the work. A copy of this f �4rft Fo orllA NT to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating U� 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: 1/22/15 B. Inventory of Equipment Tested/Certified ...4 ,h....nn-nn rb,n boxes m imtbnM cwrifir emdnment i as nertedhery iced: 1 Tank ]D- Tank IQ, ❑ In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Moder. ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model ❑ Piping Sump\ Trench Sensor (a). Model: ❑ Piping Sump\ Trench Sensor (s). Model ❑ Fill Sump Sensor (s), Model: ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Lim Leak Detector. Model: ❑ Mechanical line Leak Detector. Model: ❑ Electranic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model:i, ❑ Tank Overfill \ High -Level Sensor. Model: ❑ 'rank 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). Tari TanklD• ❑ In - Tank Gauging Probe. Model. ❑ in -'rank Gauging Probe Moder. ❑ Annular Space or Vault Sensor. Model ❑ Annular Space or Vault Sensor. Model. ❑ Piping Sump\ Trench Sensor (a) Model. ❑ Piping Sump\ Trench Sensor (a) Model: ❑ Fill Sump Sensor (a). Model ❑ Fill Sump Sensor (a). Model ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model ❑ Tank Overfill \ Iligh-Level Sensor. Model: ❑ 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• t3-tA Dispenser IQ, 75-tg M Dispenser Containment Sensor (s). Model: VR79aaao-spa ® Dispenser Containment Sensor (s) Model VR 7UUQb 20a ® Shear Valve (s). 11 Shear Valve W. ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID• Dispenser In, ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (a). ❑ Dispenser Containment Float(s)and Chain (s) Dispenser In. Dispenser ID, ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (a). Model: ❑ Shca,Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (afraid Chain (s). *If the facility contains more tanks or dispensers. copy this form. Include information for every lank and dispenser at the facility C. Certification - 1 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' checklisis I necessary to verify that this information is correct grid a Plot Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports. I have also attached a copy of the; (cheek aft feat apptt): ❑ System set-up ❑ Alarm history report Technician Name (print): Randy Wilkerson Signature: Mfg. Cert.tt.: 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 95112 Date of Testing/Servicing: 1/22/15