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MONARING SYSTEM CERTIAPATION For Ilse By A// Jurisdictions Within the State of Cal�fornia Authority Cited.- Chapter 6 7, Health andSafety Code; Chapter 16, Division 3, lifle 23, California Co& of Regulations This form must be used to document testing and servicing of monitoring equipment. for each monitoring system control D. 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 systems within 30 days of test date. A. General Information Facility Name: Unified Western Grocers Site Address: 1990 Piccoli Street city: Stockton Facility Contact Person: Pat QuilleKpLe!y Make/Model of Monitoring System: Vee der -Root TLS 350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate s ire eauitanent insnectedAerviced! Tank ID: T I –Diesel Tank ID: T 2 – Diesel ®R In -Tank Gauging Probe. Model: 847390-107 U In -Tank Gauging Probe. Model: El Annular Space or Vault Sensor. Model: 794390-420 Ll Annular Space or Vault Sensor. Model: ®R Piping Sump / Trench Sensor(s). Model: 794380-208 LJ Piping Sump / Trench Sensor(s). Model: Ll Fill Sump Sensor(s). Model: LJ Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: FE Petro L) Mechanical Line Leak Detector. Model: R LJ Electronic Line Leak Detector. Model: Ll Electronic Line Leak- Detector- Model: ri L) Tank Overfill / fligh-Level Sensor. Model: L) Tank Overfill / High -Level Sensor. I Model: 5 - mer Ll Oth equipment type and model in Section E on Page 2). LJ Other (specify equipment type and model in Section E on Page 2). Tank ID. T 3 – Waste Oil Tank ID: LJ In -Tank Gauging Probe. Model: L) In -Tank Gauging Probe. Model: QAnnular Space or Vault Sensor. Model: LJ Annular Space or Vault Sensor. Model: Ll Piping Sump / Trench Sensor(s). Model: Ll Piping Sump / Trench Sensor(s). Model: LJ Fill Sump Sensor(s), Model: Lj Fill Sump Sensor(s). Model: LJ Mechanical Line Leak Detector. Model: LJ Mechanical Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: I LJ Electronic Line Leak Detector. Model: L) Tank Overfill / High -Level Sensor. Model: ,1' Ll Tank- Overfill / High -Level Sensor. Model: Ll Other (specify equipment type and model in Section E on Page 2). Q Other (specify equipment type and model in Section E on Page 2). I Dispenser ID: Dispenser 0 1 Dispenser ID: i 0 Dispenser Containment Sensor(s). Model: 794380-420 Q Dispenser Containment Sensor(s). Model: 1XI Shear Valve(s). LI Shear Valve(s). LJ Dispenser Containment Float(s) and Chain(s). LIDispenser Containment Float(s) and Chain(s). Dispenser ID: Ll Dispenser Containment Sensor(s). Model: LJ Shear Valve(s). LJDispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: Ll Dispenser Containment Sensor(s). Model: LJ Dispenser Containment Sensor(s). Model: LJ Shear Valve(s). I Ll Shear Valve(s). ■Dispenser Containment Float(s) and Chain(s). il! L� Dis enser Containment Float(s) and Chain(s). 1][1174'Miff VIN"'I "MM"Iffl—M-00 i "101" MR, M i a' Certification No.: A-223 50 Testing Company Narne-. A & J Envirom-nental Svc's Inc. Site Address: 1990 Piccoh Street Stockton, Ca 95215 1 I1i r ON - 1" 71 nri hist 111; M_ I � Page 7 of 3 03/01