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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 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 RECEIVED Facility Name:Safeway ��n1e�e Bldg.No.: Site Address: 6425 N.Pacific Ave.M K�N^ 2 3 2017 City: Stockton,CA Zip: 95207- Facility Contact Person: Manager 'Ci Contact Phone No.: (209)472.8600 Make/Modelof Monitoring SystemEW*J)WENTALHEALTH Date of Testing/Servicing: 2/23/17 B. Inventory of Equipment Tested/Cer I Ie Check the appropriate boxes to indicate specific equipment inspected/seryiced: Tank ID•01-Regu Tank ID:02-Prem ® In-Tank Gauging Probe. Model: VR"7363-10e It In-Tank Gauging Probe. Model: VR 847360-106 ® Annular Space or Vault Sensor. Model: VR 704391t46Y ® Annular Space or Vault Sensor. Model: VR 764360460 ® Piping Sump\Trench Sensor(s). Model: VR 7"38a208 ® Piping Sump\Trench Sensor(s). Model: VR 764380-208 ® Fill Sump Sensor(s). Model: VR 764380-205 ® Fill Sump Sensor(s). Model: VR 784380-208 p Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR sense 8484 ® Electronic Line Leak Detector. Model. VR Sens.8434 ® Tank Overfill\High-Level Sensor. Model: va 130061.001 ® Tank Overfill\High-Level Sensor. Moder, VR 7No91-001 ❑ 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-Dlasel Tank ID- • in-Tank Gauging Probe, Model: VR"73W.10 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor, Model VR794360486 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump\Trench Sensor(s). Model VR 794360-208 ❑ Piping Sump\Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: VR 764380-20e ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR Sens•"84 ❑ Electronic Line Leak Detector. Model ® Tank Overfill\High-Level Sensor, Model: VR 790001401 ❑ 'rank 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 IDs 01'02 Dispenser ID* 03.04 ® Dispenser Containment Sensor(s). Model: VR784380208 ® Dispenser Containment Sensor(s). Model. VR 7"330.208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser IDs 06.06 Dispenser ID: 07.08 M Dispenser Containment Sensor(a). Model: VR 764380208 ® Dispenser Containment Sensor(6). Model: yR 794380-203 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser[D• os-10 Dispenser ID: 11.12 M Dispenser Containment Sensor(s). Model: VR794390-209 ® Dispenser Containment Sensor(s) Model: VR 794380-20a ❑ Shear Valve(s). ❑ Sheer 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- 1 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)aeues3ary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable ofgenerating such reports,I have also attached a copy of the; (check all that apply); ® System set-up ® Alarm history report i Technician Name(print): Randy Wilkerson Signature: %/., mk Mfg.Cert.#.: A32404 ICC# 5258660-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 96112 Date of TestinWServicing: 2123/17