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'Jan. 23. 2006 1 :20PM -Lv.Wklealth ` tar Env ironmenta', 1nC I %,�,XN,1 ' l�-nNo, 6876 P. 2 h or use Hy Arr rurrsaicrrons rennin the State,�rlifornia Authority citee% chapter and Safety Code; :hapier 76, Division 3 it a 23, Cali' frt!'ore C�DE�l;ZZ.14, This form must be used to document testing and servicing of monitoring eeauipment.A sensrate ceriztic aticm�r.re rrt must be pr p.,_, for each monitoring system control panel by the technician who performs the work.A copy of this forin roust be provided to the system owner/operator.The o«vnerbperator trust submit a copy of this form to the local agency regulating UST systems withi days of test date. A. General Information Facility Name: Escalon Mini Mart Bldg.No.: Site Address: 1097 E.Yosemite City: Escalon Zip: 95320 Facility Contact Person:Bill ContWt Phonic NTT.: ( 209 , 838-1546 Make/Model of Monitoring System: EBW Auto Stick Jr. Date of Tesdag/Servicing: 11 / 21 0: IL Inventory of Equipment Tested/Certified Check the appropriate bnxca to indicate specific equipment inspected/serviced: Tank Lb. Unleaded 87 Tank rD- ®•In-Tank Gauging Probe. Model: p Itr-'r augung Pro Moder: ® Annular.Space or Vault Sensor. Model. , C7 Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(%). Model: _ Ll Piping Sump/?Tench Sensor(s). Model:_ p Fill Sump Sensor(s). Model: _ 0 Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model:VM 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: _ Ci Electronic Line Leak Detector. Model- 0 Tank Overfill/High-Level Sensor.Model: p'rank Overfill/High-Level Sensor.Model: Other(sveciuui ent=and model in Section E on Pae-2), CJ Otherequipment WW and model in Section E on LILL . Tauk ID: Prer iUM 91 Tank 1D: 14 In-Tank Gauging Probe. Model: _ p in-T augmg ro . Madel: ®Annular Space or Vault Sensor. Model:kZW p Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: p Piping Sump/Trench Sensor(s). Model: p Fill Sump Sensor(s). Model: p Fill Sump Sensor(s). Model: * Mechanical Line Leal:Detector. Model: F,E,Petro _ p Mechanical Line Leak Detector, Model: E3 Electronic Line Leak Detector. Model: _ p Electronic Line Leak Detector. Model: C3 Tank Overfill/Iiigh-Level Sensor.Model: _ ©Tank Over-fill/High-Level Sensor.Model: E3 Other s .jeclkeluipment type and model in Section E on Page 2). ❑Other(specify equipment and model in Section E on Page 2). Dispenser ID. Fp#1,2 Dispenser ID- Fp#7*8 ®Dispenser Containment Sensor(s).Model: EBW CR Dispenser Containment Sensor(s).Model: EBW ® Shear Valve(s). ®Sbew Valve(s). C7 Di,5penser Containment Flogs)and Chain(s).- 0 Digponser Cantaimnent at s and Chain(s). Dispenser 1D-Fp#3,4 Dispenser IU- . .s •Dispenser Containment Sensor(s).Model: _ p Dispenser Containment Sensor(s).Model: • Shear Valve(s), 13 Shear Valve(s). Dispenser Containment Floats and Chain (s), ❑Dis enser Containment Flo a % and Chain(s), Dispenser ID- Fp#5,6 Dispenser TD- Dispenser Containment Sensor(s).Model: _ Dispenser Containment Sersor(s).Model: Shear Valve(s). . Shear Valve($). Dispenser Containment Float(s)and Chains, Dispenser Containment Floats 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 correct and a Plot Pian showing the layout of monitoring equipment.For any equipment capable of generat rig such reports,I have al,%o attached a copy of the report; (check au thdgppiy): W System set-up 0 A- }fist ry report Technicians Name(print): Nick Adamitz Signature: Q , Certification No.: 04032945 License.No.: Testing Company Name: Weststar E3nvirornmental N phone No,: (—W—) 277-937& Site Address: 4688 W.Jennifer Suite 101 Date of Testing/Servicing: 11 / 21 / 05 Page ! of 4 03.,07 Monitoring System Certification