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0 0 MONITORING 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 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring, system control panel by the technician who performs 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: Quick Stop Market #152 Site Address: 1721 S. Cherokee Ln. #1 Facility Contact Person: Michael Karvelot Make/Model of Monitoring System: Gilbarco EMC B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: City: Lodi Bldg. No.: Zip: 95240 Contact Phone No.: 510 657-8500 Date of Testing/Servicing: 08 / 18 / 2005 Tank ID: Gasoline - 87 Tank ID: Gasoline -89 In -Tank Gauging Probe. Model: 0847390-109 0 In -Tank Gauging Probe. Model: 0847390-109 Annular Space or Vault Sensor. Model: 794390-409 0 Annular Space or Vault Sensor. Model: 794390-409 Piping Sump / Trench Sensor(s). Model: 734380-208 0 Piping Sump / Trench Sensor(s). Model: 734380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ■ Mechanical Line Leak Detector. Model:yaporiess 2000 N Mechanical Line Leak Detector. Model:yaporiess 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 E on Pae 2). ❑ Other (specify equipment a and model in Section E on P e 2). Tank ID: Gasoline - 91 Tank ID: In -Tank Gauging Probe. Model: 0847390-109 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 794390-409 ❑ Annular Space or Vault Sensor. Model: N Piping Sump / Trench Sensor(s). Model: 734380-208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: vaporiess 2000 ❑ 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 e ui ment type and model in Section E on P e 2). ❑ Other (specify equipment ty a and model in Section E on Page 2). Dispenser ID: 1&2 Dispenser ID: 3&4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). E Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Floats 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 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). ❑ Dis enser Containment Float(s) 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 equip t capable of generat' g such reports, I have also attached a copy of the report; (check all that apply): ® System set-up Alarm AI history rep Technician Name (print): Bruce Stewart Signature: Certification No.: 006-05-0810 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: 08 / 18 / 2005 UN -036 - 1/4 Page I of 3 Rev. 06/04/01 CUPA: San Joaquin County Env. Health INSPECTOR: Dennis Catanyag ALT®N ENGINEERING, C,. www.unidoes.org