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Aug. 4. 2008 12:48PM tviWest Star Environmental, Inc. I urrr%.11.rlk A No. 0125 P. 2 or Use By,All Jurisdictions Within the Stategficafifornia Authority Cite& Chapter 6MVealth and Safety Code; Chapter 16, Divisio it e 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate catitication or report mmrst_be Pregar for each monitoring stem controlyanel by the technician who performs the work.A copy of this form must be provided to the tan system owmr/Operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within days of test date. A. Generali Information FacilityName: Fscalon Mini Man Bldg.No_: Site Address: 1097 E.Yosemite City: Escalon Zip: 95320 Facility Contact Person:gill Contact Phone No.. C209 ) 838-1546 Make/Model of Monitoring System• Auto Stick Jr.(EB W) Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced- Tank 110.UNLEADED Tank 10-PREMIUM ®In-Tank Gauging Probe_ Model: PROBE D91n Gauging ro _ Model: Annular.Space or Vault Sensor. Model. ❑Annular Space or Vault Sensor. Madel: ®Piping Sump/Trench Sensor(s). Model: LS-38 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: VIT Mechanical Line Leak Detector. Model: FE Petro ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: _ ®Tank Overfill/high-Level Sensor.Model: 0 N Tank Overfill/Hugh-Level Sensor. Model: []Others ment=e and model in Section E on P e a. ❑Other J&ecq e9giement type and model in Section E on P e 21 Tank ID: Tank lb: ❑In-Tank Gauging Probe. Model: ®in-Tank Gauging Probe. Model- []Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: _ ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensor(s). Model: 11)isnoM Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Teak Detector. Model: C7 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor.Model: Tank Over-fill/High-Level Sensor.Model: Other s eci a ui men# and made]in Section E on Lam 2 _ Other( ec° a ment t e and anodes in Section E on P 2). Dispenser ID-112 spenser ID.- 3/4 Dispenser Containment Sensor(s).Model: LS-39 Dispenser Containment Seiisor(s). Model: LS-38 Shear Valve(s). Shear Valve(s). Dispenser Containment n s an aut s. Dis enser Containment oats an a�n s Dispenser ID-5/6 spenser ID-7/8 Dispenser Containment Sensor(s).Model: 38 Dispenser Containment Sensor(s). Model: LS-38 Shear Valve(s). Shear Valve(s)_ Di user Con tnmen o Containment Flogff. an assts . ispenser W- ❑ Dispenser Containment Sensor(s).Model: Dispenser Containment Sensor(s).Model: El Dispenser ID- Shear Valve(s). Shear Valve(s). _ Dispenser Containment Float(s)and Chain(s). DDispenser 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 story report Technician Name(print): Andre Williams Signature L Certification No.: 5257906-UT License.No.: 605142 Testing Company Name: West Star Environmental Phone Number: (559)277-9378 Site Address: 4688W. Jennifer Suite 101 / Fresno CA 93722 Date of Testing/Servicing: 07 / 09 /08 Monitoring System Certification Page 1 of 4 03101