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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 Facility Name:Safeway Bldg.No.: Site Address: 6425 N.Pacific Ave. City: Stockton,CA Zip: 96207- Facility Contact Person: Manager Contact Phone No.: (209)472.8600 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 2/23117 B. Inventory of Equipment Tested/Certified Check 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(a). 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\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: ❑ Annular Space or Vagi Sensor, Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(a). Model: ❑ Piping Sump\Trench Sensor(a). 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 l High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section F on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2), Dispenser ID: 13.14 Dispenser ID: 18.16 ® Dispenser Containment Sensor(a). Model: VR 7943110-2118 0 Dispenser Containment Sensor(a). Model: VR 7043e0.208 ❑ Sheat-Valve(s), ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ tspenser Containment Sensor(a). Model: ❑ Dispenser Containment Sensor(a), Model: D Shear Valve(s). ❑ 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: ❑ Shmr 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 Certincation Is information(ag.monuhctures'checklists)necessary to verity 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; (cbeckall tkarapply): ® System set-up 0 .Alarm history report Technician Name(printi: Randy Wilkerson Signature: it 6-441 Mfg.Cert.#.: A32404 ICC# 5268560-UT License.No.: 486184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jos 6I esting/Servicing: 2/23/17 Y E. tysry MAR 2 3 2017 ENVIRONMENTAL HEALTH l�Cr)oQThn-