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MONI*RING SYSTEM CERTINWTION FSC CEIVED 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 nRe 1 tions This form must be used to document testingand servicing of monitorin ��" r 20 h mg g equipment. A setxtrate certification or report must be prepared for each monitorirtQ system control Hanel by the technician who performs the work. A copy of this form must befi��tALI Fi owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems wi A. General Information ES Facility Name: Ernie's General Store Bldg. No.: Site Address: 4407 E. Waterloo Rd City: Stockton Zip: 95215 Facility Contact Person: MGR Contact Phone No.: ( m: ZWf ) Make/ModelofMonitoringSyste/aa-cn Date of Testing/Servicing:1/15/2013 B. Inventory of Equipment Tested/Certified Check the aooron late bows to indicatP snP U1r P m@i ..,o..t i..o., •11 the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - f 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 alt that apply): Sy/stem set-up ® Alarm Wintery report Technician Name Charles Ferrucci Signature: Certification No.: B37512 License, Na: 962520 Testing Company Name: Henderson Maintenance Phone No.: (209) 465-5577 Testing Company Address: PO Box 31465 Stockton, Ca 95213 Date of Testing/Servicing: 1/15/2013 Page 1 of 3 Rev (2/08) �._...w . Tank ID: REGULAR Task ID: PREMUM ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: 407 E Annular Space or Vault Sensor. Model: 407 E Piping Sump / Trench Sensor(s). Model: 208 E Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: FE PETRO E Mechanical Line Leak Detector. Model: LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: E Tank Overfill / High -Level Sensor. Model: FLAPPER E 'tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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: DIESEL Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: 407 ❑ Annular Space or Vault Sensor. Model: E Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Senors). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill I High -I=t• Strom. Mv&4. ❑ Tank Overfill ( Higb-L uve& Serern. Modell ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section -E. Page 2). Dispenser ID: '1/2 Dispenser ID: 3/4 ElDispenser Containment sensor(s). Model: ❑ Dispenser Containment Sensor("s). Model: E Shear Valve(s). E Shear Valve(s). E Dispenser Containment Floats) and Chain(s). E Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). E Dispense Containment FivagS) a d0rjm(s). Di putaaa-Cuffmi anent Phrar(s) and Cham(s). I Dispenser ID: 9/10 Dispenser ID: C] Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). E Dispenser Containment Floal(s) and Chain(s). E Dispenser Containment Sway) and Chain(s). •11 the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - f 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 alt that apply): Sy/stem set-up ® Alarm Wintery report Technician Name Charles Ferrucci Signature: Certification No.: B37512 License, Na: 962520 Testing Company Name: Henderson Maintenance Phone No.: (209) 465-5577 Testing Company Address: PO Box 31465 Stockton, Ca 95213 Date of Testing/Servicing: 1/15/2013 Page 1 of 3 Rev (2/08)