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MON170RING SYSTEM CE TIF TIO <, I i ��, For Use By All Jurisdictions Within the State of California I� Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Codi ui r j ! F f � E' i This form must be used to document testing and servicing of monitoring equipment. A separate certification or r ``��A j,; e�1fe monitoring system control panel by the technician who performs the work. A copy of this form must be pr W" $ m 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 Facility Name: Kwik Sery Bldg.No.: Site Address: 950 W 11th City: Tracy Zip: 95376 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System:TLS-350 Date of Testing/Servicing: 9/2/2010 B. Inventory of Equipment Tested/Certified Check thea ro rlate boxes to indicate s cific equipment ins cted/serviced: Tank ID: Diesel Tank ID: 87 ®In-Tank Gauging Probe. Model: VR ®In-Tank Gauging Probe. Model: VR ®Annular Space or Vault Sensor. Model: 323 ®Annular Space or Vault Sensor. Model: 323 ®Piping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: ELLD ®Electronic Line Leak Detector. Model: ELLD ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑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: 91 Tank ID: ®In-Tank Gauging Probe. Model: VR ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 208 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: ELLD ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser tD: 112 Dispenser ID: 314 ®Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containment Sensor(s). Model: 208 ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 516 Dispenser ID: 718 10 Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containment Sensor(s). Model: 208 ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)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 Gavin Williams Signature: Certification No.: ICC: 8016288 License.No.: CSLB: 856771 Testing Company Name: Henderson Maintenance Company Phone No.:(209) 467-7573 Testing Company Address: PO Box 31325 Stockton, CA 95213 Date of Testing/Servicing: 9/2/2010 Page 1 of 3 j