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From: Franzen -Hill Inc. To: 12094683433 Page: 3/6 Date: 7/14/2010 4:04:28 PM 0 is Appendix VE (Copies of Monitoring System Certification form and UST Monitoring Plot Pian available at htto:llwww.waterboards.ca.gov.) MONITORINGSYSTEM CERTIFICATION For Use By Aff Jurisdictions Within the State of Califomia 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 ownerloperstor. The ownerloperator 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: Waterigg Uwrl Bldg. No.: Site Address: ----- 2512 E Waterloo City: Stockton Zip: 95205 Facility Contact Person: HenQ Contact Phone No.: 20( 9 1607-5022 MakelModel of Monitoring System: loon EM§jDate of TestinglServiang: _1Q§ „?1201 0 B. inventory of Equipment TestedlCertified Check the WRE9 Nate h=i to lndicaW specific eaulnment i r�gWIlldlearviced• Tank ID: # - 87 Regul r Tank I043 - Diesel E In -Tank Gauging Probe. Model: E In Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: E Annular Space or Vault Sensor. Model: E Piping Sump I Trench Sensor(s). Model: E Piping Sump I Trench Sensor(s). Model: E Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: it VK Mechanical Una Leak Detector. Model: Electronic Line Leak Detector. Model: E Electronic Line Leak Detector. Model: E Tank Overfill I High -Level Sensor. Model: E Tank Overfill I high -Level Sensor. Model: E 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: #2 -94 Premfum Tank ID: E In -Tank Gauging Probe. Model: E In -Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: E Annular Space or Vault Sensor. Model: E Piping Sump I Trench Sensor(s). Model: E Piping Sump I Trench Sensor(s). Model: Fill Sump Sensor(s). Model: E Fill Sump Sensor(s). Model: 11 Mechanical Line Leak Detector. Model: cis E Mechanical Une Leak Detector. Model: E Electronic Une Leak Detector. Model: E Electronic Line Leak !.Detector. Model: E Tank Overfill I High -Level Sensor. Model: E Tank Overfill I High -Level Sensor. Model: E Other (specify equipment type and model in Section Eon Page 2). E Other (specify equipment type and model in Section E on Page 2). Spenser ID: I:& '9 Dispenser ID: Dispenser Containment Sensor(s). Model: E Dispenser Containment Sensor(s). Model: Shear Valve(s). E Shear Valve(s). E Dispenser Co_ntainmenf FloatjsZand Chain_ E Dispenser Containment Floats and Chain(s). Din enserID: 3-4_._...~ Dispenser a. Dispenser Containment Sensor(s). Model: E Dispenser Containment Sensor(s). Model: Shear Valve(s). E Shear Valve(s). E Dispenser Containment Floats and Chain(s). E Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: E Dispenser Containment Sensor(s). Model: E Dispenser Containment Sensor(s). Modsl: E Shear Valve(s). E Shear Vatve(s). E Dispenser Containment Float(s) and Chains E Dispenser Containment Float(s) and Chaln(s). *if the facility contains more tanks or dispensers, copy this form. Include Information for every tank and dispenser at the faulty. C. Certification - I certify that the equipment identified in this document was inspectediserviced 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 fiat apply}: E System set-up E Alarm history report Technician Name (print): Stephen Zwahlen Signature: Certification No.:-__---j-� V4 10_L4_10 -_4q License. No.: Testing Company Name: Fr !2zSn, ill Phone No.:(.�25 i 4-6% 2�1 Z�i Testing Company Address: 1\00 N J s -r `"r j to rt C f{ �{ 3T7 �[ Date of Test€ngtSeivicing: a I I f(3 Monitoring System Certification Page 4 of 4 This fax was sent with GFI FAXmaker fax server. For more information, visit: hfp://www.gfi.com 42!07