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MONITAING SYSTEM E I N Fnr U.se By All Jurisdictions Within the State of Cali orn!a Authority Cited: Chapter 6.7, Ncadth and Safety Code; Charter.I6, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. must be nreyared for_each monitoring systcm control nancl 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. GenerallnforMSItion Facility Name: WATERLOO LIQUORS Bldg.No.: Site Address: 2512 E.WATERLOO RD City STOCKTON,CA Zip: 95205 Facility Contact Person: HENG CHEA Contact Phone No.: (209} 463-4114 Makc/Model of Monitoring System: INCON TS-S50 Date of TestinWServicing: 10/07/2009 B. Inventory of Equipment Tested/Certified Check the appm riate boxes to Indicate itie equipment inspected/serviced: Tank TD: Unleaded Tank TD: Diesel ®in-Tank Gauging Probe. Model: LCi-2 98 ®in-Tank Gauging Probe. Model: LLO-2.96 ®Annular space or Vault Sensor. Model: ULS ®Annular space or Vault Sensor. Model: ULS 23 Piping Sump/Trench Sensor(s). Modal: ULS Piping Sump/Trench Sensor(s). Model: ULS ❑Fill Sump Scnsor(s). Model: ®Fill Sump Scnsor(s). Model: ❑Mechanical Line Leak Detector, Model: ❑Mechanical Line Leak t7ctoctor. Model: ❑Electronic Linc Leak Detector. Model: ❑81c rtronic Line Leak Detector. Modal: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment typo and model in Section E an Page 2). ❑Other(specify equipment type and model in Section B an Page 2). Tank ID: Diesel Saltie 1D: ®In-Tank Gaugins Probe. Model: LLO-2 0 ❑in-Tank Gauging ftbc. Model: Annular Space or Vault Sensor. Model: ULS ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Scnsor(s). Model: ULS ❑Piping Sump I Trench Sensor(s). Model: ❑Fill Sump Scnsor(s). Model: ❑Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ❑Mechanical Linc Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic ianc Leak Detector. Model: ❑Tank Overfill/Iiigh-Lcvel Sensor. Model: ❑Tank Overfill/High-Uvel Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(speciry equipment type and model in Section E on Page Z). Dispenser iD: 1/2 Dispenser JD: ®Dispenser Containment Sensor(s). Model., ULS ❑Dispenser Containment Sensor(s), Model: Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ®Dispenses Containment Float(s)and Chain(s). Dispenser ID: 3/4 Dispenser ID: ®Dispenser Containment Sensor(s). Model ULS ❑Dispenser Containment Scnsor(s). Model: lel Shear Valve(s). ❑Shear Valve(s). [3 Dispenser Containment Fioata)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: CO Shear Vaivc(s). ❑Sher Valve(s). 0 Dispenser Containment noat(s)and Chain(s). ❑Dispenner Containment Float(s)and Chain(s). +Ifthe 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 inspect rviced In accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g, manufacturers' chlcckll is necessary to verify that this Information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipmc t ftpable of generating such reports,i have also attached a copy of the report;(check all that gppdy)c ®System set-up history report Techttician Namc(print): JUNIOR S1NCO Signature: tT Certification No.: 122621376 Liccnse.No.: tl4147 Testing Company Name: Franzen-Hill lPhonc No.: 599 688-2977 Site Address: 1100 N.J St.Tulare 93274 Date of Tcsting/Servicing: 10/7/2009 Page 1 of 3