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Monitoring System Equipment certification For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be preoared 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 Site Address: 6425 N. Pacific Ave. Bldg. Stockton, CA Zip: 95207 - Facility Contact Person: Manager Contact Phone No.: (209) 472-8600 Make/Model of Monitoring System: WR TLS -350 Date of Testing/Servicing: 1/21/14 B. Inventory of Equipment Tested/Certified Check the approprfate boxes to indicate specific equipment inspected/serviced: Tank ID: Tank ID• ❑ In - Tank Gauging Probe. Model: ❑ In .1 ank 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: p Fill Sump Sensor (s). Model. ❑ Mechanical Line Leak Detector. Model: p Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -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). Tank 10; Tank 11): ❑ in -Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Model. E3 Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: p Piping Sump \ Trench Sensor (s). Model: ❑ Piping Sump \.Trench Sensor (s). Model: D Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model. ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -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 We 13-14 Dispenser ® Ill' 1S-16 Dispenser Containment Sensor (s). Model: VR 79a3e0 208 N Dispenser Containment Sensor (s). Model'. vn 791380-2011 M Shear Valve (s). ® Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: ❑ Dispenser Containment Sensor (s). Model: Dispenser Ill:_ ❑ Dispenser Containment Sensor (s). Model: ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Disppenser ID: Dispenser IQ; Ell5fspenset Containment Sensor (s) Model: ❑ Dispenser Containment Sensor (s) Model: p Shear Valve (s). E] Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). -If rhe facility contains more tanks or dispensers, copy this form. Include information for every inns and dispenser at the facility C. Certification - t certify that the equipment identified in this document was inspected/serviced in accordance with the man. fartian Ws guideline. Attached to this CcetifcaHnn Ls information (e.g. munufaelures' checklists ) necessary to verify that thi. 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; ( checkall that apply): ❑ System sel-up ❑ Alarm history report 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: 1/21/14