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07!17/2012 18:38 (209; 465-4986 MaryAnn Henderson Page 5/12 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httoa/www.waterboards ca oov.) MONITORING SYSTEM CERTIFICATION For Use By All Junsdictions Adhin tine 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. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The ovmerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Emie's General Store Bldg, No.: Site Address: 4407 E Waterloo Rd City: Stockton Zip: 95215 Facility Contact Person: Contact Phone No.: ( 2Q9 )_ 931-2850 MakelModel of Menibmig System: _ Gilbaroe EMC Date of Testing/Servicing: 01 / 17 / 2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspacted(sarviced: TanklD: UIJLEADED87 Tank ID: SUPREME91 0 In -Tank Gauging Probe. Model: a In -Tank Gauging Probe, Model: X Annular Space or Vault Sensor. Model: 409 X Annular Space or Vault Sensor. Model: 409 X Piping Sump/ Trench Sensor(s). Model: 208 X Piping Sump/ Trench Sensor(s). Model: 208 Cl Fal Sump Sensor(s). Motley. ❑ Fill Sump Sensor(s). Model X Meorwical Line Leak Detector. Model: FE PETRO X Mechanical Line Leak Detector. Model: L02000 ❑ Electronic line Leak Detector. Model: D Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model: FLAPPER X Tank Overfill/High-Level Sensor. Model: FLAPPER D Other equipment and model in Section E on Page 2). ❑ oche 10222yipment type and model in Section E on Page 2). TankiD: DIESEL TanklD: ❑ In -Tank Gauging Probe. Model: D In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 409 ❑ Annular Space orVaut Sensor. Model; X Piping Sump/ Trench Sensoria). Madel: 208 ❑ Piping Sump/ Trench Sensor(s). Model: a Fill Sump sensor(s). Model: ❑ Fill Sump Sensor(s). - Model: X Mechanical Line Leak Detector. Model: LD2000 ❑ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: X Tank Overfill I High -Level Sensor. Model: FLAPPER ❑ Tank Overfill I High -Level Sensor, Model: ❑ Other equipment tvce and model In Section E on Paoe 2). 0 Other fsoecify equipment Mpe and model in Section E on Page 2).. Dispenser 10: PAC PRIDE 1/2 Dispenser 10: PAC PRIDE 3/4 ❑ Dispenser ContainmentSensor(s). Model: 0 Dispenser Containment Sensor(s). Model: X Shear VaVe(s). X Shear Valve(s). X Dispenser Containment Floats and Chains . X Dispenser Containment Fbaf s and Chain(s). DispenserlD: PACPRIDE 516 DisperaerlD: PACPRIDE 7/8 0 Dispenser Conlainmert Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: X Shear VaNe(s). X Shear Valve(s). X Dispenser Containment Floc s and Charts). X Dispenser Containment Floats and Chain(s). DispanserlD: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser ComalnmentSensor(s). Model: D Shear Valve(s). ❑ ShearValve(s). ❑ Dispenser Containment Floats and Chaff s 1 ❑ DisDenser Containment Floats and Chan s . ItMe tacslty contains more tanks or chtspensers, 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 verity that this information is correct and a Plot Plan showing the layout of monitoring equipment For any equipment capable of generalg-;uch repo ,1 so attached a copy of the report; (check all that apply): X System set-up X Alarm history repo Technician Name (print): CHARLES FERRUCCI Signature: i Certification No.: 837513 License. No.: 962520 Tesdrlg Company Name: Service Station Testing - SST Ing Phone No.: f209) 465-5577 Testing Company Address: PO Box 31465 Slgcicfon CA 95213 Date of Testing/Servicing: ,01(17/2012 Monitoring System Certification Page 1 of 4 12/07 2/21/07