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Nov, 14, 2006 4:48PM VlWest Star Environmental, Inc, / (-;t �+� UANo. 15591 P, 2 Pbr(Ise By All Jurisdictions Within the Stat alifornia Authority Cite& ChapterWI, Health and Safety Code; Chapter 16, Division , Tit e 23, California Code of Regulations This form must be used to document testing and servicing of nrottitOrillg equipment se arate certificati ormM ust be Pr for each monitoring m control panel by the technician who performs the work.A copy of this form must be provided to the t system owner/operator-The owner/operator must submit a copy of this forth to the local agency regulating UST systems within days of test date. A. General information Facility Name: ESCALON MINI MART Bldg.No.: Site Address: 1097 E,YOSEMITE City: ESCALON MINI MART zip: 9S32o Facility Contact Person:BILL Co 2 Contact Phone No.: ( 09_ } 83&1546 Make/Model of Monitoring System: AUTO STICK JR.(E$W) Date of Testing/Servicing: B. inventory of Equipment TesteWCertified Check the approprratc boxes to indicate specific ui went inspecieWserviced: Took 119-UNLEADED Tank W_PREM [I In-Tank Gauging Probe. Model:AUTO STrCK 3R.(EBW) In-T Gauging a Model AUTO C K JR. w ®Amlular.Space or Vault Sento. Model. Avr:o snCK JR.(ERwlr.s3A ®Annular Space or Vault Sensor. . Modeh AU M sr3c:K JRL(MiV=3A®Piping Sump/Trench Sensor(s). Model:AuTo sTrcrt JR,(13T)MAPiping Sump/Trench Sensor(s). Model:Aum STICK JR.(&e 3A C1 Fill Sump s). Model:_VMI 2 ❑Fol Stang Sensor($). Model- 19 Meelianical Line leak Detector_ Model: _ Mmeclianieal Line Leak Detector. Model:. P . - []Electrank Line Leak Detector Model: ❑Electronic Line Leat Detector. Model: Im Tank Overfill/High-Level Sensor.Model• LA . Tank Overfill/Higli-Level Sensor.Model: . TtMFIW— .Other a mint and model in Section E one,21- ®Other ent=and model In Section E on 2. Tana ID: Txnk 1D: El In Tank Gauging probe. Model: ❑In-Tank Ganging Probe. Model: tm Anlar Space or Vault Sensor. Model: _. _ ®Annular Space or Vault Sensor. Model: Piping Swap/Trench s). Model: piping Sump/T'rettch Sensor($). Model• Fill Sump Samnfs). Model: Fill Sump Sensor($) Model. Mechanical Line beak Detector. Model: ❑Mechanical Line Leak Detector. Model: Electronic Line Leak Detector: Model: Electronic Line Leak Detector. Model: Tank Ovearfill/High-Level Sensor.Model: Tank Over-fill/High-Level Sensor.Model. Other a Ot 4w and model in Section E on P e 2). Other int a and modal in 'on E on Page 2. Dispenser ID,-3&4 Dispenser Containment Sensor(s).Model: nuTo sncrc JR.LEBw s;A Dispenser Containment SenSOr(S).Model:AUTO STICK JR.MMIMA Shear valve.($). Shear Valve(s). P—Wam s $ Dis user Contariiment Dispenser ID-5$6 Dispenser ID-7&S Dispenser Containment Sensor(s).Model: Miro STICK JR.0XW 1.S3A Dispenser Containment Sensor(s).Model: AuTo sricK x(nw>Ls3A Shear Valve(s). Shear Valve(s)- Dispensa C D' containments n s_ ispenser W- ❑ Disperser Containment Sensor(s)_Model: Dispenser Containment Sensor(s)_Model: ®Dispenser ID- Shear valve(s). -- Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Cbispenser 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 hispected/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 cap g erating such reports,I have also attached a copy of the report;(check all that apply): ® System set-up !W Al fistoryport Technician Name(print): JASON ESQUEDA Signature: Certification No.:3959 License.No.: 2 Testing Company Name: West star Environmental Phone Number: (559)277-9378 Date of Testing/Servicing: Site Address: 4588 W_Jenni€er, Suite 901 / Fresno CA 93722 11 / 09 / 04 Monitoring System Certification Page 1 of 4 03101