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MONITORING' , 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 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: Quik Stop #124 Site Address: 505 N. Main Street Facility Contact Person: Michael Karyelot Make/Model of Monitoring System: Gilbarco EMC B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: City: Manteca Bldg. No.: Zip: 95336 Contact Phone No.: 510 ) 657-8500 Date of Testing/Servicing: 06 / 20 / 2006 Tank ID: Gasoline - 89 Tank ID: Gasoline - 87 In -Tank Gauging Probe. Model: 0847390-109 ■ In -Tank Gauging Probe. Model: 0847390-109 Annular Space or Vault Sensor. Model: 0794390-409 N Annular Space or Vault Sensor. Model: 0794390-409 ■ Piping Sump / Trench Sensor(s). Model: 0794380-208 E Piping Sump / Trench Sensor(s). Model: 0794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ■ Mechanical Line Leak Detector. Model: FE -Petro MLD ■ Mechanical Line Leak Detector. Model: Red Jacket FX ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on P e 2). ❑ Other (specify equipment a and model in Section E on Pae 2). Tank ID: Gasoline -91 Tank ID: In -Tank Gauging Probe. Model: 0847390-109 ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 0794390-409 ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 0794380-208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: LD -2000 ❑ 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: ❑ Other (specify equipment tye and model in Section E on Page 2). ❑ Other (sped a ui ment a and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). 0 Shear Valve(s). N Dispenser Containment Float(s) and Chain(s). 0 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 Floats 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). ❑Dis enser Containment Float(s) and Chain(s). Lp2ispenser 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 ® Al m hi tory r ort Technician Name (print): Mike Lawrence Signature: —� Certification No.: A26642 License. No.: 617238 Testing Company Name: Walton Engineering, Inc. Phone NoA 916 ) 373-1152 Site Address: 3900 Commerce Drive, West Sacramento, CA 95691 Date of Testing/Servicing: 06 / 20 / 2006 UN -036 - 1/4 COPA: Stanislaus County Env. Health INSPECTOR: Muniappa Naidu Page 1 of 3 144! NGINEERING, INC. www.unidocs.org Rev. 06/04/01