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From:Franzen-Hill Inc. To: 12094683433 Page:3/8 Date: 1/3/2013 4:57:59 PM MONOORINGSYSTIRAtT..' ` :. ATI For U.se 13v all Jurisdictions Within the State of Cali ornia authority Cited: Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23, Califarnia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. - 444tk -A separate certification or report must be p a!ted for each monitoring systemcontrol mel by the technician who performs the work. A copy of this form must be provided to the tmik system ownerloperator. The ovmer/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. *-_._ ..:_..__.._ ..Ai;;... ............. . A. General Information Facility Name: ESCALON MINI MART Bldg_No.: Site Address: 1087 E YOSEMITE AVE City: ESCALON Zip: Facility Contact Person: BILL Contact Phone No.: (209) 838.1646 Make/Model of Monitoring System: EBW AUTO STIK JR 4 ]Date orresting/Servicing: 12/2712012 B. Inventory of Equipment Tested/Certified Cheek thea ra date boxes to fndkete s c eastedtservicml+: Tank ID: 87 Tank ID: 91 ®to-Tani:Oaup,iug Probe, Model: M ®In-Tank.Gauging Probe, Model: 960 Annular Space or Vault Sensor. Model: LS3A Q Annular Space or Vault Sensor. Model: ®Piping Sump I Trench Sensor(s). Model: LS3A ®Piping Sump/Trend Sensor(s). Model: LSSA ©Fill Sump Selmr(s). Model: Ci Fill Semap Sensoa(s). Model: ®Mechanical Line Leak Detector_ Model: FXIV ®Mechanical Line l.mk Detector. Morel: FEPETRO ©Electronic Line leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/high-Level Sensor. Model: FLAPPER ®Tank Overfill l Iligh Level Senor. Model: FLAPPER 0 Odd(specify equipment type and model in Secdion E on Page 2), 13 Other(specify egaipment type and model in Sectiaro IE an tPage 2): Tank ID: Tank IA: ]In Tank Gauging Probe Model: II In-rank Gauging Probe. Model: ®Annular Space or Vault Sar". Model: ®Annular Space or Vault Sensor. Model: ®Piping Sump 1 Trench Sensor(s). Model: Piping Sump I Trench 3e (s). Model: Q Fitt Sump Sensor{s). Model: Q Fitt Sump s). Model: ®Mechanical line Leak Detector. Model: ®Mechanical line Uak Detector. Model: ®Electronic Line Leak Detector. Model: ❑Electronic Lim Leak Detector. Model: ©Tank Overfill!I ligh-Level Sensor. Model: ❑Tante Overfill./}high-Level sensor. Model: ©011ier(specify equipment type and model in Section F.on Page 2). ®Other(specify equipment type and awdel in Section E on.KW ),... Dispenser ID: 1-2 Dispenser ID: 3-41 (�Dispenser Containmmt Sensors} Model: LSSA 0 Dispenser C,,ontainm+mt Sensor(s). Model: LS3A ®Shear Valve(s). ®shear Vatvo(s). []Dispenw Containment Float(s)and Chain(s). 0 Dispetver Containment Floats)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ®Dispenser Containmem Sensors}. Model: L33A 0 Dispenser Containment Sens*s} Model: LS3A ®Shear Valve(s). ®Shear Valve(s). ❑Dispenses 0muitunent Float(s)and Chain(s). ®Dispenser Conu mint Floats)and Chaiu(s� Dispenser ID: Dispenser ID: [I Dispenser Containment Semor(s). Model: ®Diapemer Containment Swxwr(s). Model;:- ®Shear Vaive(s} ®Shear Valve(s). El Dispenser ContaWment Float(s)and Chain(s). ❑Dispenser Coatakcam FIM(s)and C tain(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/seauieed-in accordance with the manufacturers' guidelines. Attached to this Certification is information(e g.manufacturers'checkilqs,"t cessary to verify that this information is correct and a Site-Pest 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 aid that apply): � ystem seVmp''t" arm history report Technician.Name ADAM TAYLOR _ _ Signature: _... .............................. Cernri.cation No.: 5311678/2360/3387333701 I.,iceno: 8304147 _ _ Testing Company Name: 1FRANZENHILL Phone No.:( ) 698-2977 Testing Company Address: I100 N J ST TULARE CA Date of Testing(Servicing: 12127/2012 This fax was sent with GFI FAXmaker fax server. For more information,visit: http://vwvw.gfi.com