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0 0 MONITORING 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 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 St. Facility Contact Person: Michael Karyelot Make/Model of Monitoring System: Gilbarco EMC B. Inventory of Equipment Tested/Certified ('hnrli tho nnnrnnrinto hnroc to indirnto cnorit7r —ain—t incnortod/corvirrd- City: Manteca Bldg. No.: Zip: 95336 Contact Phone No.: ( 510 ) 657-8500 Date of Testing/Servicing: 6 /27 /05 Tank ID: 89 Tank ID: 87 ■ In -Tank Gauging Probe. Model: Mag Probe ■ In -Tank Gauging Probe. Model: Mag Probe ■ Annular Space or Vault Sensor. Model: 0794390-409 ■ Annular Space or Vault Sensor. Model: 0794390-409 ■ Piping Sump / Trench Sensor(s). Model: 0794380-208 ■ Piping Sump / Trench Sensor(s). Model: 0794360-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ■ Mechanical Line Leak Detector. Model: Vaporless LD -2000 ■ Mechanical Line Leak Detector. Model: Red Jacket Fx1V ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ■ Tank Overfill / High -Level Sensor. Model: oPW 61 so-EVR 0 Tank Overfill / High -Level Sensor. Model: oPW 61 s0-EVR ❑ Other (specify equipment ty e and model in Section E on Pae 2). ❑ Other(specify equipment a and model in Section E on Pae 2). Tank ID: 91 Tank ID: ■ In -Tank Gauging Probe. Model: Mag Probe ❑ 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: ■ Mechanical Line Leak Detector. Model: FE Petro STP -MLD ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ■ Tank Overfill / High -Level Sensor. Model: oPW 61 so-EVR ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment a and model in Section Eon Page 2). ❑ Other (specify equipment 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). ■ Shear Valve(s). ■ Dis enser Containment Float(s) and Chain(s). 1 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 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). ❑Dis enser Containment Floats 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): ❑Q System set-up FAjl9rm history report Technician Name (print): Phillip Kingman Signature: - - Certification No.: 006-05-0809 License. No.: 617238 Testing Company Name: Walton Engineering Inc. Phone Noj- 916 ) 373-1152 Site Address: 3900 Commerce Drive, West Sacramento, CA 95691 Date of Testing/Servicing: 6 / 27 /_05 UN -036 - 1/4 Page I of 3 Rev. 06/04/01 COPA: San Joaquin County Env. Health INSPECTOR: Ray Von Flue ALTON "ENGINEERING, INC. www.unidoes.org