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01112/2015 13:47 5596881467 FRANZEN HILL PAGE 02 , MORT t) IPTG SYSTEM CE TI CATION P'Or Use By All Jurisdictions Within the State of California Arathro-icy Cited. Chapter 67. 11calth and.Safety Code, Chapter 16, Division 3, Title 23, (.'calf{ This ibrm. must be mcd it) document testing and acrvicin of Monitoring x x t3 g cquipmcnt. trtiii ittn r rc rn� c '" �h Tmanitotitttlg system asrtt t oanci by the technician who perform9 the work. A soupy of this f rm must be provided in the �C :a s1:em mamcr/operator. he owncrfoperatur mutt suirmit a co)Sy Df this form to the local agony regulating UST systcrns within 30 days of l:cst i ti "J A. General Information Facility Name: ESCALON MINI MART MEN_~K Site Address: 1197 E. YOSEMITE City: IESCALON Zip: 95320 Facility Contact Pers cm; Bili- Contact Phone No.: 209 838-15" Make/Modcl of Monitoring System: AUTO STiK JR/4 Date of Testing/Scrvicing: 118/2015 B. Inventory of Equipment Tested/Certified Check the R=C= boxes to indicate sped e tri ent ins= Tank M., 87 Tank 113: 91 0 Tn-Tank Ctaetgrng pfribe. Model; ® Annular Space of Vauh Rencvr. ® In -Tank Gauging Prue. Malec: iNCON Model: AUTO STIK 0 Piping Sump / T=ch Sthsar(s). Model: TRp.ULS 0 Annalar Space or Vault Scmar. Model: AUTO STIK 0 piping sin t Trench RetaROr(c). Mrd; ® Fill Sump sensor(s). Model: 75P•#JLS 0 Fitt Sumba Sonsoi•(s). Model: Mechanical Lift Leak• natw r. Madel: RIM JACK T Q Etecvrniic Line I.e* Detcew. ® Methamied Liao Lcik Detector, Model: F.E. PETRO Model: ® Tank Overfill r High-T.evel Sc mRnr. Model: Q Blectro nic Line teak Detector. Modei: ® Tank ovcrfill / ITigh-Level Sensor. model; ❑ Other (specify equipment type said model in Stxdcm E on Paps 2), C3 Other (specify quonent type and model in Sectmi E on Page 2). Tank ID: fault m: Q In -Tank Gamginp Prt,bc. MOM: Q In -Tank Goaging Probe, Model: Q Aijimler Space tat Vault setter. Model: _ ❑ Amtular Space or Vault Sensor. Model: ❑ Piping Rump ! Trench 5ensor(R). Model: Q Piping Sump / Trench Smgcan{s). Model: d Fill S (s), Model! d Fill S R). l: Q Mechanical Line T?et Model: Q Mechanical i.ine Leak Detector, Model: 1310cftnie Lino Leak Delmar. Madel: Q Electronic Linc Leak rmtecte, Msadcl: ® Took Overfill / TTigt 4-rei Scaaat•. Mcdct; El Oth- (specify eqn' tyM ❑ Tank Overfill / FTigTn-Level Sensor, Modcl: ;md model in Section E on pap 2). ❑ tkhca (Rees ify ptneaat type orad rttodet in : tion F on page 2), Mqmser ID: 112 Dispenser ID: 304 ® Dispenser Containment Scnsor(R}, Model' TSP-ULS N Shrum Valve(%). _ 0 I ispen.ser Containment senser(9- T%4W: TSP41LS Q Dispenser Containment nment Mat(R) and Chain(s). ® Shear Valvas). Q 1DispcnRer C t Float(a) and Cham(ar}. Tlispenstr ii1: 5-6 Dispenser ID: 7-8 ® ijispcnscr Ctmt.,irtrricnt Ren.+�ar(R). Motel: TSP`�JLS Sbe..ar Valve(.), 10 T3ispenser Contairnwrit �rRor(R), Model: TSP.ULS u "® �l Diapetasax Crmcattnment Float(s) and Chaea(s). Rimc4t Valve(s). ] t?iRpcats¢r C F7caav(s) and C�in(R). tser ID: DispetaRer Iii` Mhscr Containment Rentcrr(s). Model:ur Va1ve(s) 100078i� Q l,tspensct C:ontait+araciit Scaanas(R), Model: -- Ctamtaerareeermt Floatts) and Chain(s). Shear Valne(t), ® TFiepcnser Ctmtninmcnt Float(R) :anti Chain(,,), •Tf the facility contains more tanks or dispensers- copy this form, include information liar every tank and dispcnw at the fatality. C. CertifiCRtion - I certify that the equipment identified in this document was iitspeetediservieed ire accordance with the manufacturers' guidelines. Attached to this Certification in information (e.g. manufacturers' ehacklift) nee msary to verity that this information is correct and a Piet )plan Rhe'sring the layout of monitoring egeai trent For any egni event capable of generating'such reports. I have also attached a copy of the report: (check all that apply): [] system qetrvp�►Barm ry report Technician Nance (print): RUBEN GALiNDO Signatu Certification Nu,: 3007133703 —` License. No.: Testing Company Name: FZEN HILL � Phone : (5591) 688-2977 Tcsting Company Address: 1100 N. J ST, TULARE CA, 9274 D ot-Testing/Scrvieing: _ Page 1 of 3