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v MONITWNG SYSTEM CERTIFIO�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. ''"eraedirA separate certification or report must be prepared for each monitorine system control panels the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must subAt form to a local agency regulating UST systems within 30 days of test date. I.:,tr::::ti01! flted OR the"aek of this pageq SEP 1 8 2006 A. General Information ENVIRQNMEWT HEALES TH Facility Name: A One Gas&Food �� PERMIT g o: Site Address: 574 W. Grantline Rd City: TracK Zip: 95376 Facility Contact Person: Contact A*,Nt%:,(209) 833-3416 Make/Model of Monitoring System: ate of Testing/Servicing: 9/14/2006 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced Tank 1D: 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(q. Model: ❑Fill Sump Sensor(s). Model: El Fill Sump Senson(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 OverfillHigh-level Sensor. 'Model: ❑Other(specify equipment type and model in Section F,on Page 2). ❑Other'(specify equipment type and model in Section 1: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: ❑pill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector., Model: ❑.Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: 11 '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 F on Page 2). El Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑Dispenser Containment Se')Rsor(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). Dispenser ID: Dispenser ED: ❑Dispenser Contiltimedt Sensor(s).'`,Modcl: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floats)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;cppy 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 Siw 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): Gavin Williams Signature: lnJ� — Certification No.: WIKT2074 License.No.: 05857 Testing Company Name: HMC-Henderson Maint Co Phone No.:(209) 467-7573 Site Address: PO Box 31325,Stoickton, CA 95213 Date of Testing/Servicing: 9/14/2006