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Jan 23 06 08: 13p Mike Dotten 209-533-2650 p. 1 r 17759 Buttercup Circle, Sonora, CA 95370 Phone: 209-532-7320; Fax. 209-533-2650 California Contractor 623541 A-Haz alltech@getrocket.com MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Madsen's Sunrise Dairy Date of Testing/Servicing: January 6,2006 Facility Address: 239 S. Stockton St., Ripon CA 95358 Facility Contact Person: Bob Madsen Contact Phone No.: 5993041 Make/Model of Monitoring System: Incon 1000 B. Inventoa of E ui ment Tested/Certified: FTank :Regular Compartment Tank ID:Premium Compartment nk Gauging Probe_ Model:None ❑In-Tank Gauging Probe. Model:None lar Space or Vault Sensor. Model:Optical sensor N Annular Space or Vault Sensor. Model:Shared wl 87 g Sump/'French Sensor(s). Modcl:None ❑Piping Sump/Trench Sensor(s). Model:Noneump Sensor(s). Model:None ❑Fill Sump Sensor(s). Model:None ❑Mechanical Line Leak Detector. Model:None ❑Mechanical Line Leak Detector. Model:None ❑Electronic Line Leak Detector. Model:None ❑Electronic bine Leak Detector. Model:None 19 Tank Overfill/High-Level Sensor. Model:Drop Tubes N Tank Overfill/High-Level Sensor. Model.Drop Tube ❑Other ❑Other Tank ID:Diesel Compartment Tank 1D: El In-Tank Gauging Probe. Model:None ❑]n-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model:Shared w/87 ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model:None ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model:None ❑Fill Sump Sensor(s). Model: ❑Mechanical Linc Leak Detector. Model:None { Q Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model:None Q Electronic Line Leak Detector. Model: N Tank Overfill I High-Level Sensor. Model:Drop Tube i]Tank Overfill 1 High-Level Sensor. Model: ❑Other ❑other Dispenser ID: 1 N Sump:[3Dry❑Water[]Product Dispenser ID:2 N Sump:ZDry❑Water❑Product ®Dispenser Containment Sensor(s). Model:Float Switch N Dispenser Containment Sensor(s). Model:Float Sw. ❑Shear Valve(s) (Functional test) ❑Shear Vaive(s) (Functional test) ❑Dispenser Containment Floats and Chains). i]Dis enser Containment Floats and Chain (s). Dispenser ID:3 Z Sump:®Dry❑Water❑Product Dispenser ID: ❑ Sump:[-]Dry❑Water❑Product N Dispenser Containment Sensor(s). Model:Float Sw. ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) ❑Dispenser Containment Float(s)and Chains. ❑Dis enser Containment Float(s)and Chain s). Dispenser ID: ❑ Sump:❑Dry[]Water[-]Product 'Dispenser ID: ❑Sump:[]Dry[]Water❑Product ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Scnsor(s). Model: ❑Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) ❑Dispenser Containment Float(s)and Chain(s). ❑Disenser Containment Floats and Chain(s). C. Certification - 1 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,l have also attached a copy of the port;(check11 that apply): ElSystem set-up ElAlarm history report Technician: Mike Dotten,California Contractor License. No.:623541 Certification: Incon:Level 3;030822980 ICC UST Technician cert#5259412'UT Page 1 of 03101