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Monitoring System Equipment Certification For Use By AUJurisdictions 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 mut be 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$600 Make/Model of Monitoring System: V/R TLS -350 Date of Testing/Servicing: 6120112 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank 111: 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 (a). Model: ❑ Fill Sump Sensor (a). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Madel: ❑ Electronic Line Leek 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 ID: Tank ID: ❑ In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe, Model: p Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump \ Trench Sensor (s). Model: Cl Piping Sump \ Trench Sensor (s). Model: ❑ Fill Sump Senor (a). 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 ID: 13-14 Dispenser ID: 15-16 - ® Dispenser Containment Sensor (s). Model: Int 794380-208 N Dispenser Containment Senor (s). Model: VR 794390408 ® Shear Vah'e (s). N Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: Dispenser IQ, ❑ Dispenser Containment Sensor (a). Model: ❑ Dispenser Containment Sensor (s). Model: ❑ Shear Valve (a). p Shear Valve(s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: Dispenser ID- ❑ Dispenser Containment Sensor (a). Model: ❑ Dispenser Containment Sensor (a). Model: ❑ Shear Valve (s). ❑ Shear Valve (s). p Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). me ramury 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 documentwas 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; (check an chat apply): ❑ System set-up ❑ Alarm history report Technician Name (print): Myke Briggs Signature: 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: 6/20/12