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A KJi& iY.» lx,� q&V mat, • 17759 Buttercup Circle, Sonora, CA 95370 Phone: 209-532-7320; Fax: 209-533-2650 California Tank Tester: 90-1068 California Contractor 623541 A-Haz alltech@mlode.com mlode.com A. General Information • MONITORING SYSTEM CERTIFICATION Facility Name: Madsen Sunrise Dairy Date of Testing/Servicing: June 21, 2002 Facility Address: 239 S. Stockton St., Ripon CA 95358 Facility Contact Person: Bob Madsen Contact Phone No.: 599-3041 Make/Model of Monitoring System: Incon 1000 B. Inventory of Equipment Tested/Certified: M Multi -compartment tank; M Single annular sensor. Check the appropriate bases to indicate specific euoipment inspected/serviced: M Pass ❑ Fail Tank ID: Regular Compartment Tank ID: Supreme Compartment ❑ In -Tank Gauging Probe. Model: ❑ (n- lank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: Optical (Shared) ® Annular Spain or Vault Sensor. Model: Shared ❑ Piping Sump / Trench Sensor(s). Model' ❑ Piping Sump / Trench Sonsor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Senso(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model i ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: Ballfloat ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other ❑ Other Tank ID: Diesel Compartment 'rank ID: ❑ In -Tank Gauging Protx:. Model: ❑ In -Tank Gauging Probc. Model: M Annular Space or Vault Sensor. Model! Shared ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model ❑ Piping Sump /1 rench Sensor(s). Model' ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic line Lcak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor_ Model: ❑ Tank Overfill / High-level Sensor. Model: ❑ Othcr ❑ Other Dispenser ID: Regular M Sump: MDry ❑ Water []Product Dispenser ID: Supreme M Sump: ®Dry ❑ Water ❑Product ® Dispenser Containment Scosor(s). Model: Float Sw. M Dispenser Containment Sensor(s). Model: Float Sw. i ❑ Shear Valve(s) (Functional test) ❑ Shear Valve(s) (Functional test) ❑ Dispenser Containment Float(s) and Chuin s _ ❑ Disnser Containment Floats) and Chain(s). _ Dispenser ID: Diesel M Sump: MDry ❑ Water ❑Product Dispenser ID: ❑ Sump: ❑Dry ❑ Water ❑Product 1 ® Dispenser Containment Sensor(s). Model: Float Sw. ❑ Dispenser Containment Sensor(s). Model: I ❑ Shear Valvc(s) (Functional test) ❑ Shear Valve(s) (Functional test) Containment Float(s) and Chains . ❑ Dispenser Containment Float(s) and Chain(s). ❑ Sump: ❑Dry ❑ Water ❑Product Dispenser ID: ❑ Sump: ❑Dry ❑ Water ❑Product Containrocnt Sensor(s). Model: rDispenscr ❑DispenserContainmentSensur(s). Model: c(s) (Functional test) ❑ Shear Valve(s) (Functional test) Containment I^loaf s) and Chain(sZ _ El Dispenser Containment Float(s) and Chain(s). C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the munufacturem' 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, 1 have also attached a copy of the report; (check all that apply): ❑ System set-up ❑ Alarm history report Technician: Mike Dotten, California Tank Tester License. No.: 90-1068 Certification: Veeder-Root: 341-32-6743; Level 3. Page I of 3 03101