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i Jun 02 04 12: 33p ike Dotten (20 1 533-2650 p. 1 � - - 17759 Buttercup Circle, Sonora, CA 95370 Phone: 209-532-7320; Fax: 209-533-2650 �{ California Contractor 623,541 A-Haz a1ltcch@gctrocket.com MONITORING SYSTEM CERTIFICATION A. General Information . Facility Name: Linden Associated Growers Date of Testing/Servicing: June 1,2004 Facility Address: 14175 E.Hwy 26,Linden CA 95326 Facility Contact Person: Charlie Bttsalacchi Contact Phone No.:209-931-4800 Regulatory agency: San Joaquin Health;Inspector:John Jackson;Phone:468-3440; Fax 468-3433 Make/Model of Monitoring System: Veeder-Root ILS-250 Phis test report is a: ®Prelimina Report&1iresetyed Issues,Exist or a: ❑ Final Report acili was observed to be in Compliance) Tank ID:Gasoline Compartment Tank ID:Diesel Compartmant ❑InTankGauging Probe. Model:None ❑In-Tank Gauging Probe. Model:None ®Annular Space or Vault Sensor. Model:Float Switch ®Annular Space or Vault Sensor. Model:Shared wvith Gas side ❑Piping Sump/Trench Sensor(s). Model:None ❑Piping Sump I Trench Sensor(s). Model:None ❑Fill Sump Smsor(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 Line Leak Detector. Model:None 10 Tank Overfill/High-Level Sensor. op Tubc Z Tank Overfill/High-Level Sensor :Drop Tube ®Fillspill buckets tested ❑Pas ®Fail Z Fillspill buckets tested ❑P s El Other ®F 1 _ ❑Other 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: ❑Eiectrottic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑FillspilI buckets tested ❑Pass ❑Fail ❑ Fillspill buckets tested ❑Pass ❑Fait Other ❑Other p ® p: ❑Dry®Water❑Product Dispenser ID: Gas N Sump:®Dry�Water ZPmduct Dispenser ID:Diesel Sum ®Dispenser Contairunent Sensor(s). Model:Float SW. 21 Dispenser Containment Sensor(s). Model:Float Switch ❑Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) ❑Di ser Containment Float(s)and Chain (s), ❑Dispenser Containment Float(s) and Chains . Dispenser ID: ❑Sump:❑Dry❑Water❑Product Dispenser ID: ❑Sump:❑Dry❑Water❑Product Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: El Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) ❑Di ser Containment Floa s and Chains . ❑Dispenser Containment Float(s) and Chain(s). Dispenser ED: 0 Sump:❑Dry❑Water❑Product Dispenser ED. ❑Sump: ❑Dry❑Water❑Product ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Sheat Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) i ❑Llis enscr Containment Float(s)and Chain (s). ❑Dis enscr Containment Floats and Chains . 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: Detyzlt Mike Dottcn,California Contractor License- No.: 623541 Certification: Veeder-Root:341-32-6743;Level 4. Page 1 of 3 03101