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RECEIVED MAR 21 2011 Appendix VI 1/IRONMEITAL Ffla`.��.M (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http:/1wjNnff4v.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited. 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.A separate certification or report must be prepared for each monitoring system control panel 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: Quick N Easy Mart Bldg.No.: Site Address: 2057 S EI Dorado City: Stockton Zip:95015 Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: Date of Testing/Servicing: 2/9/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins pected/serviced: Tank ID:1 SUPREME Tank ID: X In-Tank Gauging Probe. Model:MAG ❑ In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model:VR 409 ❑ Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model:VR 208 ❑ Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model:MLD ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model:FLAPPER ❑ Tank Overfill/High-Level Sensor. Model: CI 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:2 UNLEADED Tank ID: X In-Tank Gauging Probe. Model: MAG ❑ 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: X Fill Sump Sensor(s). Model:VR 208 ❑ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model:VMI ❑ Mechanical Line Leak Detector. Model: i:! Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model:FLAPPER ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Pae 2). ❑ Other(s a e ui ment type and model in Section E on Page 2). Dispenser ID:1/2 Dispenser ID:7/8 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). X Dispenser Containment Float(s)and Chain(s). X Dispenser Containment Float(s)and Chain(s). Dispenser ID:3/4 Dispenser ID: 9/10 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). X Dispenser Containment Float(s)and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser ID:5/6 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). X Dispenser Containment Float(s)and Chains ❑ 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 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 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 I ory 7"_ Technician Name(print):Jason Haase Signat re: Certification No.: B40970 License.No.: 920 Testing Company Name:MID VALLEY CONSULTING Phone No.:(530) 49-9892 Testing Company Address: 1097 BRONCO DRIVE,PLUMAS LAKE,CA 95961 Dat of Testing/Servicing: 2/9/2017 Monitoring System Certification Page 1 of 4 12/07 pgwa io,y? 1 2/21/07