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06/`10/2006 09:26 91637124150 SZ MANITANENCE PAGE 02/07 MONITORING SYSTEM CERTIFICATION For Use AvAll Jurisdictions Mlhln the State of California Authority Cited:. Chapter 6.7, Health mid,5glety Code; Chapter 16, Division 3, Title 23, California Code gfRegulations This form mast be used In document testing and servicing of monitoring equipment. A.,se+arOte ecrii6eation or report mast be prepared for each menu_.' orinasyst V control panel by the technician who performs the work. A copy of this form must be provided to the lank system owner/operator. The owner/operntor 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: COUNTRY MARKET PLACE Bldg.No.: Site Address: 1789 WEST CHARTER WAY City: STOCKTON Zip: 95206 Facility Contact Person: HARJINDER Contact Phone No.: 209-933-1789 Make(Model of Monitoring System:VEEDER ROOT EMC Date of Testing/Setvicing: 3/12108 B. inventory of Equipment'Tested/Certified lfieck then ro rimc boxes to indicMc a "Inc rd mens ma Wll9ervicedr: Tank ID: 87 Tank TD: 91 X In-Tank eattging Prubo. Modal: 847390-107 X_1n-Tank Clanging Probe, Mesial: 847390-007 X Anmdar .Space or Vnnli Sensor. Model: 794390-620 X Annular Space or Vault Somor. Modol: 794380420 X Piping Sump/Trench Sedsor(s). Model. 794380.208 X Piping Sump/Trench Senwr(s). Model: 794380.208 ❑ Fill Sump Sensor(s), Modcl: ❑Fill Sump Sensor(s). Model: X Mechanical Linc L.cak Iktccior. Madel: 881.02000 X Mechanical Linc Leek Detcctar. Model! 118 036 ❑Electronic Line Lank Deleetor. Model: ❑Electronic Line Lomak Datoctor. Model: X Tank overfill/HiRh-i.evcl Srncor. Model: 790091-001 X Tank Olverf II/High-I..evel sensor. Modal: 780081-001 Q Other(speafy equipment type std model in section Eon Petro 2). ❑Ohbor(specty equipment type and motel in Section E on Pogo 2), Tank ID: Tank ID: ❑In-Tank(1.wging Probe. Model: ❑In-Tank(longing Probe. Model: ❑ Atmular Space or Vault Senanr. Model: ❑Annular Space or Vault Sensor. Model: (3 Piping Sump/Trench Samar(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑ Pill sump sm"'). Model: ❑ Fill Sump Sensor(s). Model: ❑Mcchamunl Lina Look Delectm Model: 0 Mechanical Linc Look Detector. Model: ❑ Electronic Line L.cak Dolcctor. Model: ❑Elearom Lina i,eak Detector. Model: ❑Tank Overfill/Hight-Level Serum Model: []Tank Overfill/High-Level sensor. Modct: ❑Labor(specify equipment type and model in Section 13 on I?age 2). ❑Other(5peeify equipment typo and model in Saellon E on Page 2). Dispenser ID: ..1,2 . .... Dispenser iD; 3,4 X bisporocr ContainmentSenaor(s). Model: PA0596000011 X Dispenser Comainmam Srnsnr(s). Model: PAOSSS000011 X Shear Vulve(�). X shear Valvc(s). ❑ Dispenser Codnainmem Float(%)and Chnin(s). ❑ Dispemcr Containment Float(s)and Climn(s). Dispenser 11): 5,6 Dispenser ED: 7,8 X Diapenaor Containment Scnaor(s). Model: PA0696000011 X biapcnscr Coouumoanl Scmor(s). Model: PA0595000011 X Shear valve(s). X Shear Valve(s). ❑ Dispenser Comiinnient Float(s)and Chain(s). ❑Dispen5or Containment Flnxgs)and Cha(n(s). Dispenser ID: 9,10 Dispenser ID: 11,12 X Dispenser Crntnimnent Sortnr(s). Model: P.A0696000011 X Dispenser C:rmtainmmt Sonsor(a). Model: PA0695000011 X Rimr Volvo(.). X Shear Valvc(s). ❑ Dispenser Contomenenl FDoal(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(a). *If the Facility contains more tanks or dispensers,copy this fort. 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 manufacturer' guidelines. Attached to this Certification is information (e.g. manufacturen' checklists)necessary to verify that this Information Is correct and a Plan showing the layout of monitorings equipment. For any equipment capable of genenting such reports,i have also attached a copy of the report; (check all drat app(p): ys Set-up X Alarms history report Technician Name _ r _JAMES WILLIAMS Signal Certification No . A32464 License. No.: 433159 Testing Company Name: B.Z. Service Station Maintenance PhoneNo.:-916 371-2380 Site Address: 630 Houston Street West Sacramento, CA 95691 Date of Testing/Servicing: 3112/08 Pape 1 of 3 DIN-036—1/4 nww.unddnca.orp Rev-0126/06