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MONI RING SYSTEM CERT IF ATION For Use By All Jurisdictions Within the State of California Authority Cite&-Chapter 6.7,Health and Safety Code; Chapter 16,Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more duin on lem eeatfel panel is installed at *he f eifit A separate certification or report must be prepared for each monitoring system control cartel 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 a copy of this form to the local agency regulating UST systems within 30 days of test date. . A. General Information Facility Name: ESCALON MINI MART Bldg. No.: Site Address: 1097 E YOSEMITE AVE City: ESCALON Zip: Facility Contact Person: BILL Contact Phone No.: (209) 838-1546 Make/Model of Monitoring System: EBW AUTO STIK JR 4 Date of Testing/Servicing: 1/9/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate s c equipment ms serviced-: Tank ID: 87 Tank ID: 91 ®In-Tank Gauging Probe. Model: 960 ®In-Tank Gauging Probe. Model: 960 ®Annular Space or Vault Sensor. Model: LS3A ❑Annular Space or Vauh Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: LS3A ®Piping Sump/Trench Scr—r(s). Model: LS3A ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: FXIV ®Mechanical Line Leak Detector. Model: FEPETRO ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: FLAPPER ®Tank Overfill/High-Level Sensor. Model: FLAPPER ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s)_ Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Madel: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ®Dispenser Containment Sensor(s). Model: LSSA ®Dispenser Containment Sensor(s). Model: LSSA ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ®Dispenser Containment Sensor(s). Model: LS3A ®Dispenser Containment Sensor(s). Model: LS3A ®Shear Valve(s). ®Shear Vatve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Cham(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: 1 ❑ Shear Valve(s). ❑Shear Valve(s). JAN 0 9 20114 ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser atMMONMENTAL C. Certification - I certify that the equipment identified in this document was inspected/serviced"9AkWQEl WTdl ENTte manufacturers' guidelines. Attached to this Certification is information(e.g. manufacturers' checklists)necessary to verify that this information is correct and a Site-Plot 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 all that apply): ® System set-up ® Alarm history report Technician Name ADAM TAYLOR Signature: Certification No.: 5311578/2350/3387333701 License. No.: 8304147 Testing Company Name: FRANZENHILL Phone No.:(559) 688-2977 Testing Company Address: 1100 N J ST TULARE CA Date of Testing/Servicing: 1/9/2014