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• • 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 :3, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report mut be prepared for each monitorine system control panel by the technician who perforins 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: GEORGE KISHIDA TRUCKING Site Address: 1725 ACKERMAN DR Facility Contact Person: KELLI Make/Model of Monitoring System: OMNTEC B. Inventory of Equipment Tested/Certified County: SAN JOAQUIN City: LODI Contact Phone 209-368-0603 Date of Testing/Servicing: 11/18/2016 Tank ID: T1- DSL Tank ID: T2- DSL ® In -Tank Gauging Probe. Model: MAG ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: BXPDWF ® Annular Space or Vault Sensor. Model: SPLIT ® Piping Sump / Trench Sensor(s). Model: BX -LS ® Piping Sump / Trench Sensor(s). Model: BX -L5 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model ® Mechanical Line Leak Detector. Model: FX1DV ® Mechanical Line Leak Detector. Model: FX1DV ❑ 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. Model: ❑ 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 (specity equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s), Model: V ailed] vatvctsl• ❑ Dispenser Containment Float(s) and Chain(s). o Ducal rur,"a1. ❑ Dispenser Containment Float(s) and Chain(s). Check the appropriate holes to indicate specific equipment inspected/serviced: 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 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 eport Technician Name (print): RHOME DESBIENS Signature: .----- Certification 112111RD License No.: 433159 Testing Company Name: B. Z. Service Station Maintenance Phone No.: (916) 371-2380 Site 1041 Triangle Court West Sacramento, CA 95605 Date of Testing/Servicing: 11/18/2016 Monitoring Certification Test Report 1 of 4