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From: Franzen-Hill Inc. To: 12094683433 Page:318 Date: 1/20/2014 4:36:47 PM MONOORMSYSTEM.- M For Use ByA11 Jurisdictions Within the State of California Authority Cited:-Chapter 6.7,Health and Safety Code,Chapter 16,Division 3, 71de 23, California Code of Regulations This form must be used to document toting and servicing of monitoring equipment at the—A1c ity;a separate ca 'an r re m f� tori em nitroa by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit eopy`c ,t*it form to the local agency regulating UST systems within 30 days of test date. LL A. General Information IV . Facility Name: ESCALON MINI MART r Site Address: 1097 E YOSEMITE AVE City: ESCALON Facility Contact Person: BILL Contact Phone No.: 208 838-1546 Make/Model of Monitoring System: EBW AUTO?STIK JR 4 late of Testing/Servicing: 1/912014 B. Inventory of Equipment Tested/Certified C:hecktim a boxes to indicate collie ul ut b►. l."rvi": Tank ID: 87 Tank ID: 91 ®in-'rank Gauging Probe. Mo&-L Sao ®in Tank Gauging Probe. Modal: dell ®Annular Space or Vault Sensor. Model: LS3A ❑Annular Space or Vault Sensor. Mndel: ®Piping Sutup/Trench Sensor(s), Model: LSSA ®Piping smv/Tremb Saosor(s). Model: L83A Q Fill Sump Sensor(s). Model: ®Fitt Sump Smsor(s). Model: 1 ®Mec haoieal Une leak Detector. Model: FX1V ®Mechanical line 1.cat.Detector. Model: FEPETRO Q Electronic Line Leak Detector. Model. Q Electronic Line leak Detector. Modal: ®Tank Overfill/High-Level Senses Model: FLAPPER ®Tante Overfill I High-Level Scow. Model: FLAPPER- ®Other(specify equipment type and model in Section E on Page 2) Q Other(specify mpsip awot type and nwdol in Station E on Page 2). Tank ID: Tank ID: Q to-Tank Clanging Probe. Model: ®In-Tank oaatging Probe_ Model: Q Annular Space or Vault Sensor, ❑Annular Space or Vault Sensor, Model: ®Piping Sump/Tr s). Q Pipieg Sump/Tremch s). Modch ( Fill Sump Seimr(s). Model: Q Fill Sump Sensor(s). Model: Q Mechanical Line Leak Detector. Model: Q Mechanical Line LeakDeteetor. Madel: Q.Electronic Line Leak Detector. Model• Q Mcctsonic lane Leak Detector. Model: ©Tank Overfill 1 High-Level saasor. Model: Q Tank Overfill/High-Level Sensor. ?nodal: Q Other(s4cify equipment type and model in Section E on Page Q Other(specify equipment type and model in Section E on Page 2). Dispenser W: 1-2 Dispenser ID. 34 0 Dispenser Contaiiancnt Sensor(s) Model: LSSA IR Dispenu r Containmerit Seasor(sl Model; LSSA ®Shear Vatve(s� 19 Shear Vatvc(s). Q Dispenser Containment Floats)and Chain(s). Q Dispm=Containmaxt Floats)std Chain(sA Dispenser ID: 6-6 Dispenser ID: 74 ®Dispenser Containment Semor(s). Model: LS3A ®Disperim Containment Sensor(s). Modal: LS3A ®Shear Valve(s). ®Shear Valve(s). Q Dispretzer Containment Float(s)and Chain(s). Q Dapeom Contamment'Ftoat(s)and Cha&t(s). Dispenser ID: Dispenser ID: Q134mer Containmets Sm or(s). Model: Q DiVeri=Containment Senso(s} Model: ©Shear Valve(s). ®sheat Valve(s). Q Dispenser Containmem Floats)and Chaio(sj, Q D spowes Coaftaimat Float(s)and Chains} *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 is correct and a 8 te--Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report,(check an that apply); �System set-up ED Alarm history report Technician NameADAM TAYLOR Signature: Certification No.: 631157, 235013387333701 License.No.: BiO414,7 I Testing Company Name: FRANZIEWHILL Phone No.: 559 688-2977 Testing Company Address:1100 N J ST TULARE CA Date of Testing/Servicing: 119/2014 This fax was sent with GFI FAXmaker fax server. For more information,visit: hftp://www.gfi.com