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MONIING SYSTEM CERTIFI TION 13ECEIVED � 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 IZOR ,9n�Ah This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepa�fb1"' monitoring_ system control panel by the technician who performs the work. A copy of this form must be provided to the gNMENZAL The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. .ruA. General Information TI#r"Ir Facility Name: COUNTRY MARKET Site Address: 1524 FRESNO AVENUE Facility Contact Person: MIKE ELIASON Make/Model of Monitoring System: GILBARCO EMC B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: City: STOCKTON Bldg. No.: Zip: 95206 Contact Phone No.: (209) 948-9412 Date of Testing/Servicing: 3/1212015 Tank ID: DIESEL Tank ID: Z In -Tank Gauging Probe. Model: MAG ❑ In -Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: VR 420 ❑ Annular Space or Vault Sensor. Model: Z Piping Sump / Trench Sensor(s). Model: VR 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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 Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). 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 / 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: 1 SAT Dispenser ID: 1/2 Z Dispenser Containment Sensor(s). Model: GILBARCO 320 ® Dispenser Containment Sensor(s). Model: GILBARCO 320 Z Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 2 SAT 13 SAT Dispenser ID: 3/4 Z Dispenser Containment Sensor(s). Model: GILBARCO 320 Z Dispenser Containment Sensor(s). Model: VR 208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ 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 manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' 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, 1 have also attached a copy of the report; (check all that apply): Z System set-up Z Alarm history report Technician Name (print): RICHARD THOMAS Certification No.: 834022 Signature: i — a v---5 License. No.: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Phone No.: (707) 779-4999 Testing Company Address: P.O. BOX 5850, RIVERSIDE, CA 92517-5850 Date of Testing/Servicing: 311212015 Page 1 of 4 UN -036 — www.unidoes.org Rev. 01/17/08