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i MONI*PdNGSYSTEM CERTIFIWTION 4 For Use By All Jurisdictions Within the State ofCalifornia Authority Cited.•Chapter 6.7,Health and Safety Code; Chapter 16, Division 3, Titje 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate cer ification 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 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 SERVE Bldg.No.: Site Address: 950 .11TH ST City: TRACY Zip: 95376 Facility Contact Person: PATEL Contact Phone No.: (209) 832-1810 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 10/20/2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates cific Equipment inspected/serviced: Tank ID: DSL Tank ID: 91 ®In-Tank Gauging Probe. Model: MAG-1 ®In-Tank Gauging Probe. Model: MAG-1 ®Annular Space or Vault Sensor. Model: 409 ®Annular Space or Vault Sensor. Model: 409 ®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: PLLD ®Electronic Line Leak Detector. Model: PLLD ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: El 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: 87 Tank ID: ®In-Tank Gauging Probe. Model: MAG4 ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 409 ❑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: PLLD ❑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 ID: 1-2 Dispenser ID: 3-4 ®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: 5-6 Dispenser ID: 7-8 ®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 a uipment. For any equipment capab f generating such reports,I have also attached a copy of the report;(check all that apply): Lj System set-up ❑Alar ory report Technician Name(print): HEATH MCEVER Signature: Certification No.: A27662 License. 5236756-UT Testing Company Name: SST-SERVICE STATION TESTING Phone No.:(209) 465-5577 Testing Company Address: PO BOX 31465 STOCKTON CA 95213 Date of Testing/Servicing: 40901200-q— Page 1 of 3 /a