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From: Franzen -Hill Inc. To: 12094668r334r3�3+ Page: 3/7 Date: 7/7/2011 11::1T4:45 AM l\ �' 1 s• 1\�r i�?1e L 11I� L� Far Use By Add Jurisdfetfons Within the State of Cadffornia Authority Cited.• Chapter 6.7, Health and Safety Code; Chapter 16, afvisdon 3, Titde 23, Cadffornfa Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification of report rmtrt prepared for elg h monitoring syn Mel 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: Waterloo Liquors Bldg. No.: Site Address: 2512 Waterloo rd. City: Stockton Ca, Zip: Facility Contact Person: Heng Contact Phone No.: (209) 463.4914 Make/Model of Monitoring System: lncon TS -S50 Date of Testing/Servicing: 6130/20/1 B. inventory of Equipment Tested/Cerhfed Check the appropriate boxes to indicate specific equipment inspected/serviced: Tanis LD: 87 Tank ID: 91 Split ® in -Tank Gauging Probe, Model: TS 0 In -Tank Gauging Probe. Model: TS ® Annular Space or Vault Sensor. Model: ULS ® Annular Space or Vault Sensor. Model: ULS ® Piping Sump / Trench Sensor(s). Model: ULS 3A ®Piping Sump / Trench Sensors}. Model: ULS 3A ❑ Fill Sump Sensors), Model: El Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: VMI ® Mechanical Line Leak Detector. Model: VMI 0 Electronic Gine Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor, Model., Flapper Valve ® Other (specify equipment type and in Section E ® Tank Overfill / Nigh -Levet Sensor. Model: Flapper Valve model on page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: Diesel Split Tank ID: 9 In -Tank Gauging Probe. Modell. -TS ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: ULS 3A ® Piping Sump / Trench Sensor(s). Model• ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line leak Detector, Model: VMI ❑ Mechanical Line leak Detector. Model: ❑ Electronic Line Leak Detector, Model: ❑ Electronic Line Leak Detector, Model: Tank Overfill / High -Level Sensor, Model: Flapper Valve ❑ Tank Overfill / High -Level Sensor. Model: [l Other (specify equipment type and model in Section IS on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 112 Dispenser ID: 314 0 Dispenser Containment Sensors), Model: ULS 3A ® Dispenser Containment Sonsor(s). Model: ULS 3A ® Shear Valve(s). 0 Shear Valve(s). Q Dispenser Containment i:loat(s) and Chain(s), ❑ Dispenser Containmcat floats) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensors). Model: ❑ Dispenser Containment Sensors). Model: © Shear Valve(s), ❑ Shear Valve(s). Dispenser Containment floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: [j Dispeaser Containment Sensors). Model: ❑ Dispenser Containment Sensors), Model: ❑ Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s), l] Dispenser Containment Floats) 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. Cert cation - I certify that the equipment identified In this document wasjinspemecterviced in accordance with the manufacturers' guidelines, Attached to this Certiircatlon is information (e g. manufacturernese ry to verify that this information is correct and a Plot Flan showing the layout of monitoring a ulpment. For anyepagenerating such reports, I have also attached a copy of fire report; (check all that System applp): set-up istory report Technician Name (print): Jesse Vera Signature: Certification No.: 5563453702/5268608 -UT License. No.- Testing Company Name: Franzen -Hill ,Phone No.: (SSS) 688-2977 - Testing Company Address: 9100 M .i St, - Tulare Ca. Date of Testing/Servicing: 6/30/2011 Page 1 of 3 This fax was sent with GFI FAXmaker fax server. For more information, visit: http://www.gfi.com