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Aug. 16. 2004 10: 34AMTACNA No- 1413 P. 2 MONSORING SYSTEM CERTIF T10'114 '7 is po UyeByAll.Jurisdictions Within the State of e - ' Regulations Authority Cite& Chapter 6 7, Health and Safety Code; Chapter 1-6,Division 3, TilIR23, California Code of latio s or UMor arced This form must be used to docurnent testing and servicing of monitoring equiPitient.A sVpirate--certification t�mt b�ec a� r each Mgnitorga sXstoLcontr2_1 panel by the technician who performs the work.A copy of this form must be provided to the tank system owner/operator.The ownevoperator must submit a-F.7 11 this form to the local agency regulating UST systems within30 days of test date. A. General Information Bldg.No FacilityName: FSCALON NEN MART ESCALON Zip: 95320 Site Address: 1097 8.YOSENflTE City:Contact Phone No_ LlLg ) 546 BILL _L3�94 Facility Contact Person: g: 07 1, 08 MAe/Model of Monitoring System. EBW(AUTO STICK jR,) Date of Testing/Servicing L04 a. Inventory of Equipment Tests /Certified Cheek the appropriate boxes to indicate specitic,c3uipment inspected/serviced- Tank rjD.UNUADED I! Tank ED-PREM Model: EBW(AUTO STICK JR.) o.In-Tank c7auging Probe, Model: EBW AUTO&Fla JR. R In-Tank augii3g ProbeSTICK R. 0 Annular.Space or Vault Sensor. Model. 'FBW(Ago S7c��R.) I@ Annular Space or Vault Sensor. Model: ERW(AUTON CM piping Sump/Trench Sensor(s), Model- (s). Model- EBW(AUTO SJR.) N piping Sump/Trench Sensor TICK 0 1Esw(AUTO s'r[CK Jit. 1[3 Fill Sump Sensor(s)- Model:110 Fill Sump Sensor(s), Model; ❑ n-PE �� 0 Mechanical Line Leak Detector. Model:j� ET Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector, Model 13 Electronic Line Leak Detector. Model: Sensor.Model: FLAP SR_ 0 Tank Overfill/High-Level Sensor.Model, FLAPPrR_ 0 Tank Overfill/High-Level Sens r2 and model in Section E on 2). 0 other igecify equip3ent 2E.2aujd2model in 13 Other Wecify equipment ty !ELL- Tank ID- lrank'ED: [3 In-T Gauging Probe. Model: D In-Tank Gauging Pro Model; Ll Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model, 0 piping Sump/Trench Sensor(s). Model: r]piping Sump/Trench Sensor(s). Model-, 0 Sensor(s), Model: 13 Fill Sump Sensor(s). Model: Fill Sump 0 Mechanical Line Leak Detector, Model. [I Mechanical Line Leak Detector. Model: [] eeironic Line Leak Detector. Model: [3 Electronic Line Leak Detector- Model: El CIT ank Overfill I Iligh-Level Sensor.Model'. 0 Tank Over-fill/High-Level Sensor.Model-, EonP e2). 13 Other(TEZI�equipmeet type and model in Section E 0 Other(-spee!_qa equipment type and model in Section Dispense I r ID: 1&2 Dispenser jD_3&4 ).Model: M Dispenser Containment Sensor(s),Model:FBW(AUTO STICK JR.) 0 Dispenser Containment Sensor( 10 Shear Valve(s). 10 Shear Valve(s). 0 DispenseT.Containment F!2pgs)and Chains. Q DiMenser Containment�Float s.�and Cha�ins Dispenser ID- 5&6 Dispenser]D-I&S Dispenser Containment Sensor(s).Model: EBw(AUTOSEICK 111 0 Dispenser Containment sensor(s).Model-, EBw(AUTO ST[CK Tit, Shear Valve(s). M Shear Valve($). �ent Floats and Chainis). 13 Dispenser Containment Flo s)and Cbain(s). 0 Dispenser Containment Dispenser ID- Dispenser 113- Sen r(s).Model: Q Dispenser Containment Scrisor(s).Model: Dispenser Containment Shear Valve(s). Shear Valve(s)_Di neer Containment Float(s)and Chains is neer Containment Flo sand Chains. •If the facility contains more tanks or dispensers,copy this form_include information for every and dispenser at the'fae!lity. C, Certification-i certify that the equipment identified in this dacument was inspected/serviced in accordance with the cturers' ation is guidelines.Attached to this Certification is information(e.g.manufacturers'checklists)necessary to verify that this Svc also correct and a Flat Plan showing t e layout0 monitoring attached a coy of the report; (check all that apply). N System set-up Alarm history report Technician Name print): JASON, ESQUFDA Signature: Certification No.: 3959 License.No.: 605142 Testing Company Name: WEST STAR ENWRONMENTA-L Phone No.: (_52_)_22 Site Address: 4688 W.JENN FRESNO,CA 93722 Date of TestiRg/Servici-A—R, 07 1 09 1 04 Page 1 of 4 03101 Monitoring System Certification