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Aug 19 03 10:13p Charity Miles (209) 533-2650 p.l .4a c 17759 Buttercup Circle, Sonora, CA 95370 Phone: 209-532-7320; Fax: 209-533-2650 California Contractor 623541 A-Haz c a' alltech@getrocket.com getrocket.com MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Madsen's Sunrise Dairy Date of Testing/Servicing: August 19, 2003 Facility Address: 239 S. Stockton St., Ripon CA 95358 Facility Contact Person: Bob Madsen Contact Phone No.: 599-3041 Make/Model of Monitoring System: [neon 1000 B. Inventory of E ui ment Tested/Certified: Tank ID: Regular Compartment Tank 1D: Premium Compartment ❑ In -Tank Gauging Probe. Model: None ❑ in -Tank Gauging Probe. Model: None N Annular Space or Vault Sensor. Model: Optical sensor ® Annular Space or Vault Sensor. Model: Shared w/ 87 ❑ Piping Sump / Trench Sensor(s). Model: None ❑ Piping Sump / Trench Sensor(s). Model: None C1 Fill Sump Sensor(s). Model: None ❑ Fill Sump Sensor(s). Model; None ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None ❑ Electronic Line Leak Detector. Model: None ❑ Electronic Linc Leak Detector. Model: None ® Tank Overfill / High -Level Sensor. Model: Drop Tubes N Tank Overfill / High -Level Sensor. Model: Drop Tube ❑ Other ❑ Other Tank ID: Diesel Compartment Tank ID: ❑ In -Tank Gauging Probe. Model: None ❑ In -Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: Shared w/ 87 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: None ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: None ❑ Fill Sump Scnsor(s). Model: ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: None ❑ Electronic Line Leak Detector. Model: N Tank Overfill / High -Level Sensor. Model: Drop Tube ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other ❑ Other Dispenser ID: 19 Sump: ®Dry []Water ❑Product Dispenser ID: 2 N Sump: ®Dry ❑ Water []Product N Dispenser Containment Sensor(s). Model: Float Switch N Dispenser Containment Sensor(s). Model: Float Sw. ❑ Shear Valve(s) (Functional test) ❑ Shear Valve(s) (Functional test) ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float s) and Chains . Dispenser ID: 3 N Sump: NDry ❑ Water ❑Product Dispenser ID: ❑ Sump: ❑Dry ❑Water []Product N Dispenser Containment Sensor(s). Model: Float Sw. ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s) (Functional test) ❑ Shear Valve(s) (Functional test) ❑ Dis enser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chain s). Dispenser ID: ❑ Sump: ❑Dry ❑ Water ❑Product Dispenser ID: ❑ Sump: []Dry []Water ❑Product ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s) (Functional test) ❑ ShearValve(s) (Functional test) ❑ Dispenser Containment Floats and Chain(s). ❑ DispEnser Containment Flogs and Chain(s). 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 equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ❑ System set-up ❑ Alarm history report Technician: /q/k 1916141 Certification: Incon: Mike Dotten, California Contractor License. No.: 623541 Page I of 3 03101