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MONITORING SYSTEM CERTIFICAT ORWEDD 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, Califord oc ovions This form must be used to document testing and servicing of monitoring equipment.A separate ce re ared for each monitoring,system control panel by the technician who performs the work. A copy of this f the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regu a tng s within 30 days of test date. A. General Information Facility Name: Quik Stop#121 Bldg.No.: Site Address: 1196 W. Louise Ave. City: Manteca Zip: 95336 Facility Contact Person: Michael Karvelot Contact Phone No.: 510 657-8500 Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 05 /31 /2006 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: Gasoline-87 Tank ID: Gasoline-91 ® In-Tank Gauging Probe. Model: 0847390-109 0 In-Tank Gauging Probe. Model: 0847390-109 • Annular Space or Vault Sensor. Model: 0794380-303 0 Annular Space or Vault Sensor. Model: 0794380-303 • Piping Sump/Trench Sensor(s). Model: 0794380-208 ® Piping Sump/Trench Sensor(s). Model: 0794380-208 ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ■ Mechanical Line Leak Detector. Model: FE-Petro MLD ■Mechanical Line Leak Detector. Model: LD-2000 ❑ 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 a and model in Section E2E_tage 2 . ❑Other(specify a ui ment a 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 a and model in Section E on P e 2). ❑Other(specify equipment a and model in Section E on P e 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). 0 Shear Valve(s). Dis user Containment Floats and Chain(s). ® Dis nser Containment Float(s)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). 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). ❑Dis enser Containment Floats and Chain(s). ❑Dispenser Containment Float(sj 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 ®Alarm history Mort Technician Name(print): Mike Lawrence Signature: Certification No.: 006-05-2104 License.No.: 617238 Testing Company Name: Walton Engineering,Inc. Phone No.:( 916 ) 373-1152 Site Address: 3900 Commerce Drive,West Sacramento,CA 95691 Date of Testing/Servicing: 05 / 31 / 2006 UN-036-1/4 Page 1 of 3 Rev.06/04/01 CUPA: San Joaquin Co. Env. Health ALTON INSPECTOR: Muniappa Naidu ENGINEERING, llffry www.unidocs.org