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MONIORING SYSTEM CERTIODATION For Use By,All Jurisdictions Within the Slate Qf California A whority,Cited:-Chapter 6.7, Health and Safety Code: Chapter 16, Division 3, Title 23. California Code #'Regulalions This fibrin must be used to document testing and servicing of monitoring equipment. - "1 "4111 1 ltx4-ai 44� w _44A4.-a-A separate certification or report must be prepared for each illonitorinj= trot a 0lp,7tonn,the ork. -III to file local agency copy of this form Must be provided to the tank system o%kner/operalor. 'I'lic owl*,r/(W)"r a rep 1+t 2�- 1 regulating i ng Ul ST systems within 3 0 days of test date. e j1UN 1 A. General Information ENVIRONMENTAL HEA - Facility Name: H& M KWd,,. Na.IK SERVE BW98 �__�R it r-k t"T, Site Address: 2501 E.JACKSON City: MO Zip: 95320 Facility Contact Person: MIKE Contact Phone No.: (209) 838-3971 Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 8/30/2017 B. Inventory of Equipment Tested/Certified Check thea ro riatboxes to indicates ecific equipment inseected/servicedt:_ Tank ID: 87 Tank 1D: 91 ®In=fank Gauging Probe. Model: VEEDER ROOT 0 In-Tank Gauging Probe. Model: VEEDER ROOT •Annular Space or Vault Sensor. Model: 420 0 Annular Space or Vault Sensor. Model: 420/SPLIT Piping Sump/Trench Sensor(s). Model. 208 0 Piping Sump/Trench Sensor(s). Model: 208 iI ❑Fill Sump Sensor(s). Model: E]Fill Sump Sensor(s). Model: Mechanical[-me Leak Detector, Model: VMI1 LD2000 0 Mechanical Line Leak Detector. Model: RED JACKET/FXIV El Electronic Line Leak Detector- Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: VEEDER ROOT NTank Overfill/high-Level Sensor. Model: VEEDER ROOT 171 Other(specify equipment type and model in Section E on Page 2). E]Other(specify equipment type and model in Section E on Page 2). Tank ID: DIESEL Tank ID: In-Tank Gauging Probe. Model: VEEDER ROOT ❑III-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 420 ❑Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 208 ❑Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: RED JACKET FXIDV n Mechanical Line Leak Detector, Model: El Electronic Line Leak Detector. Model: C3 Flectronic Line Leak Detector. Model: gTank Overfill f High-Level Sensor. Model: VEEDER ROOT ❑Tank Overfill/High-Level Sensor. Model: 0 Other(specitv equipment type and model in Section'E on Page 2). f_1 Other(specify equipment type and model in Section Fon Page 2). Dispenser ID: 112 Dispenser ID: 3/4 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: Shear Valve(s)- N Shear Valve(s). Dispenser Containment Float(s)and Chain(s). N Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: [3 Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: E]Shear Valve(s). Fl Shear Valve(s), 171 Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: n Dispenser Containment Sensons). Model. El Dispenser Containment Sensor(s). Model: C]Shear Valve(s). El Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). *H`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 SW4Plot 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 aft that apple,): System set-up Alarm history report Technician Name(print): PETER WESTBROOK Signature: 64VA6:44W_ t Certil'icallion.No.: B46675 Licensc_. Testing Company Name: L.C.SERVICES Phone No.:(559) 444-1730 Testing Company Address: 3887 N VALENTINE FRESNO CA 93722 Date of Testing/Servicing: 8130/2017 I IN-036-1/6 wwwamidocs.org Rev.0 1/1 7!(;,s