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Monitoring System Equipment ?ertification 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 ppared 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) 472-6600 Make/Model of Monitoring System: V/R TLS -350 Date of Testing/Servicing: 1116/13 B. Inventory of Equipment Tested/Certified Cheek the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: Tank ID: ❑ In - Tank Gauging Probe. Model: ❑ In - Tank 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: ❑ 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). TanklD: Tank ❑ ID: In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe, Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump \ Trench Sensor (s). Model: ❑ Piping Sump \ Trench Sersor (s). Model: ❑ Fil Sump Sensor (s). 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 \High -Level Sensor. Model: ❑ Tank Overfill 1 High -Level Scosor. Model: ❑ Other ( specify equipment Type and model in Section E on Page 2). ❑ Other ( specify equipment type and model in Section E on Pago 2). Dispenser ID: 13-14 Dispenser ID• 15-16 0 Dispenser Containment Senior (a). Model:YR 794790-108 ® Dispenser Containment Sensor (a), Model: vR70a3210-20e 11 Shear Valve (s). 0 Shear Valve (s). ❑ Dispenser Containment Float (a) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser -11111- Dispenser ID: ❑ Dispenser Containment Semnr(a). Model: ❑ Dispenser Containment Sensor (a). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). Cl Dispenser Containment Float (s) and Cbain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: ❑ Dispenser Containment Sensor (a). Model: Dispenser ID: ❑ Dispenser Containment Sensor (9). Model: ❑ 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 identined in this document was inspcctcdtscrviced 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 equipmeoL For any equipment capable of generating such reports, I have also attached a copy of the; (ckeckall thalspply): ® System set-up 11 Alarm history report Technician Name (print): Randy Wilkerson Signature: 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