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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. AAs pante certification or report must be nreoared for each monitoring vstem control pa_el 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: VIR TLS -350 Date of Testing/Servicing: 1116113 B. Inventory of Equipment Tested/Certified Check the appropriate bores to indicate specific equipment Inspected/aerviced: Tank ID: 01-Regu Tank ID: 02 -Prem R In - Tank Gauging Probe. Model: VR 847390-109 0 In - Tank Gauging Probe. Model: VR 847390-109 ® Annular Space or Vault Sensor. Model: VR 794390460 11 AnnWar Space or Vault Sensor. Model: VR 78/790460 ® Piping Sump \ Trench Sensor (s). Model: VR 794380-208 ® Piping Sump 1 Trench Sensor (s). Model: VR 7UM-20 ® Fill Sump Sensor (s). Model: VR 7947a0-208 ® Fill Sump Sensor (s). Model: VR 794380-208 [I Mechanics] Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR Sadao 9434 ® Electronic Line Leak Detector. Model: VR Badu 8484 ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High -Laval 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 ID: 03 -Diesel Tank ID: 3 In - Tank Gauging Probe. Model: VR 87390-109 ❑ In - Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 794790-460 ❑ Annular Space or Vault Sensor. Model: R Piping Sump \ Trench Sensor (s). Model: VR 794380 -ens ❑ Piping Sump \ Trench Sensor (s). Model: ® Fill Sump Sensor (s). Model; VR 714300-29a ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR Sades 848 p 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 ID: 01-02 Dispenser ID: 03.04 R Dispenser Containment Sensor (s). Model: VR 794380.208 19 Dispenser Containment Sensor (a). Model: YR 794380-201 0 Shear Valve (s). ® Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser 1% 05-06 Dispenser Wa 07.08 9 Dispenser Containment Semor(s). Model: VR 78780-208 ® Dispenser Containment Sensor (a). Model: VR 794380-208 ® Shear Valve (s). ® Shear Valve (s). [I Dispenser Contaffirmat Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 09-10 Dispenser W, 11.12 H Dispenser Containment Sensor(s). Model: VR 794390-209 ® Dispenser Containment Sensor(s). Model: VR 794330-29e 0 Shear Valve (s). 0 Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). -If the facility, contains mom 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/servieed in accordance with the manufacturer's guidelines. Attached to this Certification is information (ag. manufactam' 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, I have also attached a copy of the; (check all thatappio: ® System set-np 11 Alarm history report Technician Name (print): Randy Wilkerson Signature: L11/I 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 95112 Date of Testing/Servicing: 1116113