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., nl <br /> MONI*RING SYSTEM CERTIF*TION <br /> For Use By All Jurisdictions Within the State of Cali./ornia <br /> Authority Cited.• Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Calif a Regulations <br /> This form must be used to document testing and servicing of monitoring equipment. A s e certification each <br /> monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tante system <br /> owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems wid*OV d of"date. <br /> A. General Information ENVIRONMENT <br /> Facility Marne: Quick Stop Marketq�^ TM <br /> 2057 S EI Dorado City: Stockton Zip: 95206 <br /> Contact Pierson: Contact Phone No.: (209) 463-6474 <br /> Make/Model of Monitoring System:TLS-300 Date of Testing/Servicing: 11/22/2010 <br /> B. Inventory of Equipment Tested/Certified <br /> Check thea nate boxes to indicate specific a ui ment lns:�ctar!!­•n--a• <br /> Tank ID: 87 7 ­­-_­_=• R1 <br /> I D4 In-Tank Gaueine Probe. Model: VR i N In-Tank Gaueine Probe. M(wi: %0 r% <br /> ;;lar g zee nr haul*. <br /> For. <br /> Model: 409 ❑ Annular Space or Vault Sensor. <br /> 1 M Pinine Sumn/Trench Sensor(s). Model: 209 1 M Pinine Sumo/Trench Senors). Model: 209 1 <br /> m n Fill Ca-min C,ncrr(c). M[utrl' 1 U Fill Cnnin Remor(cl. Mn<lol 1 <br /> 5a Mechanical Line Leak Detector. Model: FE Petro I ®Mechanical Line Leak Detector. Model: 208 <br /> q a a i_«•,.,,n,< nc k i:w• ,•,•. i ieeiee: i1 ❑LlectronicLine Leak Detector. Model: <br /> 1 1=l Tank rOverfill/Hieh-level Sensor- Model: { n Tank Overfill/Hieh-level Sensor- Moder <br /> — -- <br /> n -i::I g"•:1"1:..�� �,Paz. f-1 r u e I_.,e,,:r;.Neu _,:,:a k'pe and.-ncdL.in S,ction E :P� <br /> Tank ID: <br /> ■ in i anK traugm¢rrone model: L i In-I'ank Gauging Probe. Model: <br /> ' h1; ,1 ❑Annular Space or Vault Sensor. Model: <br /> U rnpmg Hump!r Much Nensor(s), model: ❑Piping Sump/Trench Sensor(s). Model- <br /> 1. uviii�umn�cnsoris). vi<uiei: ❑rill Sump Sensor(s). Model: <br /> i ❑Mechanical line leak Detector. Model: ❑Mechanical Tine Leak Detector. Model: <br /> i 1 1 Eicctronic Linc Lcak Detector. Model: ❑Eicctronic Linc Lcak Detcaor- Model: <br /> .._,_. -r, MIA I. Tint(Tger!,+-11/TTi _7rnl C_., <br /> _. eqsor. Model: <br /> and model in Section Eon Page 2). <br /> Dispenser ID 314 <br /> Dispenser COIItainmcraScrsc.. <br /> ®Shear Valve(s). ®Shear Valve(s). __. <br /> ®Dispenser Containment Float(s)and Chain(s). ®Dispenser Contaimtent Float(s)and Cha*s). <br /> Dispenser ID: 516 71$ <br /> ❑Dispenser Containment Sensor(s). Model: L-1 i i(slx_os r i -..— <br /> ®Shear Valve(s). <br /> s) A Dispenser Containment Heetfcl„-1• _- <br /> ®Dispenser Containment Float(s)and Cham{..,. t ��.sr+e.W_. _..........._.. .._�-3 c��„- <br /> Dispenser ID. Dispenser Iii: <br /> i i i r;�,w,.c...I"nnMinmon�Cona.,.+al Ad�.iPi• M nic.,A..�.r.,,.r.,i..,.....a Q-4 A,i.�.etA- s <br /> Is u Shear Valve(s). ❑Shear Valve(s). I <br /> 1:::! t tis---nser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). <br /> *If the f cilia;contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certification - I certify that the equipment identified in this document was inspected-rserviced in accordance with tete <br /> manufacturers' .uideEnes <br /> information is correct and a Pint Plan showing the layout of monitoring equipment. For any equipment capable of generating such <br /> Technician Name Gavin INiiliarre �io(i ritltc: � <br /> Certification No.: 8016288-U-1 ;.��«, �_ 'Y .. Z=_Z. 856771 <br /> Mendeosan Maintenance Comipany Phone No.:(209) 467-7573 <br /> Testing Company Address: PO Box 31325�Su,tt G T t 11?2atp <br /> Page 1 of 3 <br />