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07/17/2012 18:38 (209) 465-4988 MaryAnn Henderson Page 2/12 MONILRING SYSTEM CERTHICAON For Use By All Jurisdictions Within the State ofCalffornla 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 most be Preen d for each monitoring system control panel by the technician who performs the work A copy ofthis 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: Ernie's General Store Bldg. No.: Site Address: 4407 E Waterloo Rd City: Stockton Zip: 95215 Facility Contact Person: MGR Contact Phone No.: (209) 931-2850 Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 1/17/2012 B. Inventory of Equipment Tested/Certified Check the auorooriaM boxes to indicate snmifir mnio,o>..t:....>..t.am...,:..a. e am ny cant res more tanks or dispensers, copy 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 Plot Plan showing the layout of monitoring equipment. For any equi ent capable "nerating such reports,! have also attached a copy of the report; (check a/1 that apply):®Sysfe - Ala �ryrll Technician Name (print): Charles Farrucei Signature: Certification No.: B37613 License. No.: 962520 Testing Company Name: Service Station Testing, Inc. Phone No.: (209) 465,W7 Testing Company Address: PO Box 31465 Stockton CA 95213 Date of Testing/Servicing: 1/17/2012 Page 1 of 3 Rev (2/08) Tank1D: UNLEADED87 Tank ID: SUPREME 91 ❑ In -Tank Gauging Probe. Model: ❑In -Tank Gauging Probe. Model. E Annular Space or Vault Sensor. Model: 409 E Annular Space or Vault Sensor. Model: 409 E Piping Sump / Trench Sensor(s) Model: 208 E Piping Sump / Trench Sensce(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: FE PETRO ❑ Mechanical Line Leak Detector. Model: LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: FLAPPER E Tank Overfill l High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment type and made[ in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DIESEL Tank ID: ❑ IoTank Gauging Probe. Model: ❑ Io -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Seosor, Model: ® Piping Sump / Trench Sensor(sy Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Screar(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Lim: Leak Detector. Model; ❑ Electronic Lim: Leak Detector, Model: ® Tank Overfill /High -Level Sensor. Model: FLAPPER ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section Eon Page 2). ❑ Otherci (spe fy equipment type and model in Sectron E on Page 2), Dispenser M; 112 DispenserlD: 314 ❑Dispenser Containment Sensor(s). Mmcl: ❑ Dispenser Corasu nem SereeKs). Mod;; ® Shear Valvc(s), E Sheer Valve(s). ® Dispenser Containment Flom(s) and Chain(s). E Dispenser Containment Float(s) and Chain(s). Dispenser ID: 516 Dispenser ID: 718 ❑Disperser Containment Sensot(s). Model ❑Dispenser Containmem Sensor(s). Model: E Shear Valve(s), E Shear Valve(s). E Dispenser Containment Floal(s) and Chain(s). E DispenserComai mem Float(s) and Cham(s) Dispenser )[W 9/10 Dispenser ED: 11/2,3/4,5/6,7/8 Pac PridelOtherPagea ❑ Dispenser Contawnent Sensor(s). Model ❑ Dispenser Containment Sensm(s). Model: E Sheer Valve(s). E Shear Valve(s). E DisperuerComainatent Fiom(s) and Chain(s). E Dispenser Containment Float(s) and Cham(s) alftn r 'r e am ny cant res more tanks or dispensers, copy 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 Plot Plan showing the layout of monitoring equipment. For any equi ent capable "nerating such reports,! have also attached a copy of the report; (check a/1 that apply):®Sysfe - Ala �ryrll Technician Name (print): Charles Farrucei Signature: Certification No.: B37613 License. No.: 962520 Testing Company Name: Service Station Testing, Inc. Phone No.: (209) 465,W7 Testing Company Address: PO Box 31465 Stockton CA 95213 Date of Testing/Servicing: 1/17/2012 Page 1 of 3 Rev (2/08)