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r RECE1,\JEU MON11ORI NG SYSTEM CERTIFI ATI ON1) '0 1' P-or Use/3y All,lurisdicfions Within the State qf('411i6)rnia JUN 13 'L ') Authority Cited: Chapter 6.7. Health and Sqleti�Code, Chapter l6, Division 3, "Title 23, Califiwnia Code v/-Rc,EIu lati inti L Thr` form must be used to document testing and servicing ofmoniloring equipment.4"iot elm E NVIR, 0 WA E A 4it: liiOfil, A-senarate certification or report most be prepared 14 each monitorip_q s stem control and by the technici, ic iorws,11w,,kork. -- -.3_-p rr A copy of this form must be provided to the tank system owner/operator. I'lie owner/operator must submit a copy of this forin lo the lm:al regulating UST systems within 30 days of test date. A. General Information Facility Name: H&M KWIK SERVE BW98 Bld(,. No.: Site Address: 2501 E.JACKSON City: MODESTO Zip: 95320 Facility Contact Person: MIKE Contact Phone No.: 838-1 971 --- - ------ " Make/Model of Monitoring System: VEEDER ROOT TLS-360 Date of Testing/Servicing: 8/30/201,7 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicate specific equipment inspected/serviced!: Tank ID: 87 Tank 11): 91 lit-!'ank Gaug-;ng,Prnhx, as j %IEEDER ROOT M In I Model: VEEDER ROOT Annular Space or Vault Sensor. Modcl: 420 Annular Space or Vault Sensor. Model: 420/SPLIT Piping Sunip/Trench Sensor(s). Model: 208 Piping Sump/ French Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: El fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: RED JACKET FXIV 0 Mechanical Line Leak Lielector Model: VMV LD2000 ❑Electronic Line Leak IX-tector. lvlodcl0 F.lectronic Live Leak Detector Model: 01 ank VEEDER ROOT 4 + r,.! Overfill 1 High Mode!: VEEDER ROO T E3 Other(specify equipment type and model in Section E on Page 2). El other(speciN equipment type and model in Section L.on),a,24:2) Tank ID: DIESEL Tank ID: Z In-Tank Gauging Probe. Model: VEEDER ROOT ❑In-Tank 6auging,Probe. Model: ti Annular Space or Vault Sensor. Model: 420 ❑Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 208 D Piping Sunip VUrench Sensor(s) Model: El 1--ill Sump Scnsor(s) Model: El I:ili Sump Sensor(s). Model Mechanical Line Leak Detector. Model, RED JACKET FX1 DV f-1 I Mechanical Line Leak Detector, Model: — 0 Flectronic Line Leak Detector. Model. El I-lectronic Line Leak Detector. Model: NTank Overfill/High-Level Sensor. ModcL VEEDER ROOT El lank Overfill/High-Level Sensor. Model: El Other(specify equipment type and model in Section L on Page 2), 0 Other(sciR,equipment type and model in Section I Dispenser ID: 1/2 Dispenser IpeD: 3/4 El Dispenser Containment Sensor(s), Model: 0 Dispenser Containment Sensor(s). Model: Shear Valve(s). 141 Shear Valvels). Dispenser Containment Floats)and Chain(s). Z Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: Ul)ispenserCt)iitaiiiiiieriiSelisor(s). Model, 0 Shear Valve(s). ❑ Shear Valve(s), El Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID- Dispenser ID: i 71 Dispenser Containment Sensons). Model: F-1 Dispenser Containment Scrisor(s), Model 0 Shear Valvee s I r-1 Slwar Valvepo 0 Dispenser Containment Hems)and Chain(s). Dispenser Coontainment Float(s)and Chain(s) Ifthe facility contains more tanks or dispensers.cop) this t1orm. Include information for every tank and—dispenserai the fticiIiiN 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 S44e 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 app(v): System set-u Z Alarm history report Technician Name(print): PETER WESTBROOK Signature: Certificaiion N(.),: 846675 lccn , o,: Testing Company Name: L.C.SERVICES Phone No.:(559) 444-1730 Testing Compariv Address: 3887 N VALENTINE FRESNO CA 93722 Date of TestinofServicin : 8/30/2017 C, -—--—----, VN-036-1/6 Rev.0 1 A7108