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MONITdRING SYSTEM CERTIFICATION 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 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 tMer puLT,pe provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regu g S Ny o✓ithin 30 days of test date. SAN J0 oG,,1N CSU A. General Information HEALTHRMENTALTY Facility Name: COUNTRY MARKET PLACE Bldg.No.: HDEPARTHEN T Site Address: 1789 E.CHARTER WAY City: STOCKTON Zip 95206 Facility Contact Person: Stephanie Looney Contact Phone No.: (209) 933-1789 Make/Model of Monitoring System: Gilbarco EMS Date of Testing/Servicing: May 24,2005 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific a ui ment inspected/serviced: Tank ID: 87 OCTANE Tank ID: 91 OCTANE In-Tank Gauging Probe. Model: I7 In-Tank Gauging Probe. Model: (x)Annular Space or Vault Sensor. Model: 794390-420 ❑x Annular Space or Vault Sensor. Model:79439-420 () Piping Sump/Trench Sensor(s). Model: ❑O Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: U Fill Sump Sensor(s). Model: ElMechanical Line Leak Detector. Model:RED JACKET ❑x Mechanical Line Leak Detector. Model:RED JACKET ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: U Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Page 2). 17 Other(specify equipment a and model in Section E on Page 2). Tank ID: Tank ID: 13 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: I7 Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 13 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: Q Other(specify equipment a and model in Section E on Pae 2). ❑ Other(specify equipment type and model in Section E on Pae 2). Dispenser ID:#1 &#2 Dispenser ID: 7&8 (a)Dispenser Containment Sensor(s). Model: PA02 ❑O Dispenser Containment Sensor(s). Model:PA02 M Shear Valve(s). ©Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats and Chains . Dispenser ID:#3&4 Dispenser ID:9&10 ®Dispenser Containment Sensor(s). Model:PA02 ©Dispenser Containment Sensor(s). Model:PA02 IM Shear Valve(s). IM Shear Valve(s). ❑ Dispenser Containment Floats and Chains . ❑ Dispenser Containment Floats and Chain (s). Dispenser ID:#5&6 Dispenser ID:Sump#11 & 12 ©Dispenser Containment Sensor(s). Model:PA02 O Dispenser Containment Sensor(s). Model:PA02 ©Shear Valve(s). ©Shear Valve(s). ODis enser Containment Floats and Chain (s). Ll Dis enser Containment Floats and Chain (s). -If the facility contains 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 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 Name(print): MIKE JONES Signature Mike Jones Certification No.: 006-05-0616 License.No.: 309105 Testing Company Name: Stockton Service Station Equipment Co.,Inc. Phone No.:Q09)464-8333 Site Address: 1789 E. Charter Way Date of Testing/Servicing: May 24,2005 Page 1 of 3 03/01 Monitoring System Certification