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MONITORING SYSTEM CERTIFICATION For Use DPAII Jurisdidioas Withm the Stale of Cal'omia Auihortty Cited-Chapter 6-7,Heallh aadSafely Code;Chapter 16,Dmakia ,Title 23,California Code ofRegulahoas This form must be used to document testing and servicing of monitoring equipment A sellamte certification or report moat be prepared for each morritoring,system control panel by the technician who performs the work A copy of this form most he 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 FacilityName: Emil's Food Mart Bldg.No.: Site Address: 1405 Califomia St City: Escalon Zip: 95329 Facility Contact Person: Jason Contact Phone No.: ( ) Make/Model of Monitoring System: EMC Date of Testing/Servicing: 6/20-7/11106 B. Inventory of Equipment Tested/Certified Check the appropriate bores b indicate spedfic t' serviced: Tank to. 1 (87) Tank to: 2 (91) ®m Tank Gauging Probe. Model: MAG2 ®In-Tart:Gauging Probe. Model: MAG2 ❑AnnularSpace err Vault S.. Model: ❑Annular Space or Vault Sensor. Model: ®Aping Sump/Trench Sensor(s) Model:208 ®Piping Sump/Larch Scum(.) Model: 208 ❑Fill Sump Sensor(s) Model: ❑Fi8 Sump SeweK.).. Model, ®Mechanical Lure Leak Detector. Model: I--'(.-2 ®Mechanical Lin.Leak tMxtor. Model: 17-2 ❑Electronic Line Leak Dilator. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High.Lwcl Same. Model: ❑Tank overfill/High4an el Seamy. Model: ❑Other(specify equipment type and model is Section E on Page 2). ❑Other(specify equipment type and modd in Sectim Eon Page 2)- Tankilt 3 (DIESEL) Tank ID: ®In-Tank Gauging Probe. Model: MAG2 ❑to-Tank Gauging Probe Model: ®Amular .Spaceor Vauh Sensor. Model:420 ❑Annular Sparc or Vault Sensm. Model: ®Piping Sump/Trench Scrace(s) Model 208 ❑Apmg Sump/Trench Saam(s) Madel ❑Fill Sump Sensor(s) Mod.]: ❑Fill Sump S..(.). Model: 0 Mechanical Line Leak Delesto, Model:Flt-2 ❑Mechaniia l Lin.Leak Dilacor. Model: ❑Electrenie Line Leak Demeter. Model: ❑Electronic Line Leak Ddector, Model ❑Tank Overfill/High-Level Sensor Model: ❑Tack Overfill/High-level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model or Section Eon Page 2) Dispenserm: 1/2 Dbpooserm: 314 ❑fhspenss Containment Scmerfs)i Model: ❑Ihspaner Covtaonnem Sssm(s). Model: ®Shear Valvc(s) ®Sheer V.We(s). ®Dopiness Containment Float(s)and Chaio(s). ®Disp.Coram uumt Float(.)and Chwn(s) Dispenser IAspmxr ID: ❑Disperser Containment Sanson(s) Model: ❑Dispaacr Cmus mens Scewr(s). Model: ❑Shear Valve(s) - ❑Shear Vaha,(s) ❑Dispenser Commonest Float(s)and Chariots). ❑Dig.Containment Float(.)and Chain(.) Dispenser ID: ollsiairser in: ❑Dispems Containment Sonans) Model: ❑Dispenser Containment Sensor(.) Model: ❑Shear Valve(.) ❑Shear Valves) ❑Dispenser Containment Float(s)and Chnii(s). ❑DispenaT Containment Float(s)and Chain(s). "Ifthe facility contains none 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 inspecteNserviced in accordance with the manufacturers' guidelines. Attached to this Certification is information(e.g. manufacturers' checklists) necessary to verify that this infornmtimn is correct and a Piot Plan showing the layout of monitoring equiprrtem. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all then apply): ®System set-up ❑Alarm history report Technician Name(print): Carl"Wayne"Henderson Signature. y f-- Certification Certification No.: 5252923-UT License.No.: 856771 Testing Company Name: HMC-Henderson Maint Co Phone No.:(209)467-7573 Site Address: 1405 Calitomia St-Esealon Date of Testing/Servicing: 7111/2006 Page 1 of 3