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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 he 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: WR TLS -350 Date of TestingtServicing: 10/17/12 B. Inventory of Equipment Tested/Certified Check the appropriate bores to Indicate specific equipment inspected/serviced: Tank M, 01-Regu Tank ID: 02 -Prem ❑ In - Tank Gauging Probe. Model: VR 847390.199 ❑ In - Tank Gauging Probe. Model: VR 847380-109 ❑ Annular Space or Vault Sensor. Model: M 79439046 ❑ Annular Space or Vault Sensor. Model: VR 79438o460 ❑ Piping Sump i Trench Sensor (s). Model: VR 794380-208 ® Piping Stapp \ Trench Sensor (s). Model: VR 794.180-208 ❑ Fill Sump Sensor (s). Model: VRna3e0-208 ❑ Fill Sump Sensor (s). Model: VR 79480.208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: VR 9.ri.a 8484 ❑ Electronic Line Leak Detector. Model: VR Series 8484 ❑ 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 M, 03 -Diesel Tank ID: ❑ In - Tank Gauging Probe. Model: VR 847390-108 ❑ In - Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model- VR 794390 90 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump \ Trench Sensor (s). Model: VR 794380-288 ❑ Piping Sump \ Trench Sensor (a). Model:- odel❑ Ci Fill Sump Sensor (s). Model: VR 794380208 ❑ Fill Sump Sensor (a). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model VR s.d.. 8484 ❑ 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). Disppenser ID: 01-02 Disppenser ID. 03-04 ® Dispenser Containment Sensor (a). Model: VR naso -208 ® ISisparser Containment Sensor (a). Model: VR784390.208 ® Shear Valve (s). ® Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Disp enser ID: Oli-O6 Dispenser 1D: 07-08 ® Dispenser Containment Serum (a). Model: VR79OM208 ® Dispenser Containment Sensor (s). Model: VR 794380.293 ® Shear Valve (s). ® Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 09-10 Dispenser ID: 11-12 III Dispenser Containment Sensor (s). Model: VR 79480 208 Id Dispenser Containment Sensor (s). Model: yR 794380 -los ® 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 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, I have also attached a copy of the; (ebeckalltkatapply): 0 Systemset-up 0 Alarm history report Technician Name (print): Myke Briggs Signature: f/"4/�= - Mfg, Cert.#.: B38235 ICC# 8033115 -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: 10/17/12