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MONITAING SYSTEM CERTIM TION 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 systems within 30 days of test date. A. General Information FacilityName: COUNTRY MARKET Site Address: 1524 FRESNO AVENUE Facility Contact Person: MIKE EL/ASON Make/Model of Monitoring System: GILBARCO EMS B. Inventory of Equipment Tested/Certified City: STOCKTON Contact Phone No.: Bldg. No.: Zip: 95206 Date of Testing/Servicing: 3/26/2013 Check Me appropriate ooxes to muICatC s CCjjjC C uI11... Tank ID: DIESEL Tank ID: ® In -Tank Gauging Probe. Model: MAG E]In-TankGauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: E 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: : k Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: lar Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: g Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ump Sensor(s). JEJ Model: ❑ Mechanical Line Leak Detector. Model: anical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: onic Line Leak Detector. Model: ❑ Tank Overfill /High -Level Sensor. Model: Overfill / Hi -Level Sensor. �Other Model: (specify equipment type and model in Section E on Page 2).r (specify equipment type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: #1 SAT ® Dispenser Containment Sensor(s). Model: 011 / 2 WIRE ® Dispenser Containment Sensor(s). Model: 011 / 2 WIRE E Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3/4 Dispenser ID: #3 SAT ® Dispenser Containment Sensor(s). Model: 011 / 2 WIRE ® Dispenser Containment Sensor(s). Model: 011 / 2 WIRE ® 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(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). f '1' *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the act ity. 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, I have also attached a copy of the report; (check all that apply): ® System set-up ® Alarm history report Technician Name (print): RICHARD THOMAS Signature Certification No.: B34022 License. No.: 803705 Testing Company Name: TANK- TEK ENVIRONMENTAL CORPORATION Phone No.: (707) 446-6151 Testing Company Address: 607 ELMIRA ROAD, PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: 3/2612013 Page 1 of 4 UN -036 — www.unidocs.org Rev. 01/17/08