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01-15-'13 11:03 FROM-West Star Envmt Inc. +559-277-0106 T-904 P0002/0003 F-453 MONIARING SYSTEM CERTIFI CITION For Use By Alt Jurisdictions Within the State of California Authority Cited; Chapter 6 7,Health and Safety Code;Chapter 16,Division 3,17de 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate ifIcati nor report must he pmgAfor each monitoring fiygt4m contMl mel by the technician who performs the work. A copy of this foraf must be provided to the tank system owner/operator, The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: ESCALON MINIM T Bldg.No.: Site Address: 1097 E.YOSEMITE City: ESCALON Zip: 95320 Facility Contact Person: BILL Contact Phone No.: (209) 838-15 Make/Model of Monitoring System: Date of Testing/Servicing: 1/14/2013 9. Inventory of Equipment Tested/Certified Check the appMrlate boxes to indicate ocific MR!pment inspected/serviced: [Tank ID; Tank 1D- 0 ln4T;uik Gauging Probe. Model: ❑ht-Tank Gauging Probe. Model: r L]Annular Space or Vault Sensor, Model: 0 Annular Space or Vault Sensor. Model: Piping Sump/1!rench Sensor(s), Model-, L,S�j El Piping Sump/Trench Scmor(s). Model: Fill ill Sump Seflaor(s). Model: fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: [3 Electronic Lint Lok Dcwtor, Model: Q Moctronic LAno Leak Detector. Model: 0 Tank Overfill i fth-Level Sensor. Model: C)Tank Overfill i High-Level$ortsor, Model; 0 Other(specify equipment type and model In Section 13 on Page 2). Other(specify equipment type and model in Section B on Page,2), Tank ED: Tank ID- ❑In-Tank,Gauging Probe. Model: []In-Tank Gauging Probe Model: ❑Annular Space or Vault Sensor. Model: n Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: [I Piping Sump/Trench Sensor(s). Model: [3 Fill Sump Smaor(s), Model: Fill Sump Sensor(s), Model: D Mechanical Une Leak Detector. Model: Mechanical Line Leak Detector. Model: [I Electronic Line Leak Detector. Model: ❑Electronic Line I&A Detector. Model: [3 Tank.Overfill/High-1.4vol Sensor. Model; (3 Tank Overfill/High-Lovol Sensor. Model: Other(specify equipment type and model in Section E on Page 2). (3 Other(specify equipment typo and model in Section E on Page 2). Dispenser ID! Dispensex Efi- ❑Digpmw Containment Sensor(s). Model: E3 Dispens4 Containment Sensor(s), Model: Shear Valve($). . [I Shear A dve(s). [3 Dispenser Containment Float(s)and ChainW. 13 Dis�4;Containment Float(s)and Chain(s). Dispenser ED: DiSpeEder 11D: E3 Dispenser Containment$cnsor(s). Model: 0 Dispenser Containment Sonsor(s). Model: [I Shear valve($). 0 Shear Valve(s). [3 Dispenser Containment Float(s)and Chain(s). [I Dispenser Containment Float(s)and Chain(s). Dispenser FD: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: El Dispenser containment Sewor($). Model: Cl Shear Valve(s). Q Shear Valvo(s). [I Dispenser Containment Noat(s)and ChaWsy ❑Dispenser Containment Floats)and Chain(s), *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification -I certify that the equipment identffied in this document was ins serviced in accordance with the manufacturers' guidelines. Attached to this Certification is infonuation(e.g. manufacturers' dw1clists) neemary to Yerity that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any empment capable of generating such reports,I have also attached a co"of the report;(check all that apply). ❑system$d-up n Alarm history report Technician Name(print): JASON PERRY Signature: Certification No,: 8032720 License.No.. 134561 Testing Company Name. WEST STAR ENVIRONMENTAL,INC. Phone No,:(559) 277-9378 Testing Company Address: 4770 W.JENNIFER AVE.,FRESNO,CA 93722 Date of Testing/Servicing. 1114/2013 Page I of 3 Rev(2/08)