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� 0 MONITORING SYSTEM CERTIFICATION Fplryq/�U� r 3 Z00 �O For Use BPAl/Ambdletrons Within the State ofCah7omia 'pry Auihmvry Cited Chapter 6.7,HealthSafety Co&,-Chapter 16,Divisrort3 Title 23,Calijonria Cak Ibis form must be used to document testing and servicing of monitoring equipment yF� y menitnrinp,ystern nom, l by the technician who performs the work. A copy of this form must be provided to the tank system owner/op r. 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: Emil's Food Mart Bldg.No.: Site Address: 1405 California St City. Escalon Zip: 95329 Facility Contact Person: Jason Contact Phone No.: ( ) Make/Model of Monitoring System: EMC Date of Testing/Servicing: 6120-7111/06 B. Inventory of Equipment Tested/Certified Check the appropriate bases to indicates 'fie enuipmenti serviced: Tank lD 1 (87) TanklD: 2 (91) 0lo-Tank Gauging Probe. Model: MAG2 ®den-Tank Gauging Probe. \1,,dc1. MAG2 ❑Annular Space or Vault Sena. Model: ❑Annular Space or Vault Sensor Model: ®Piping Sump/Trench Sensor(s). Model: 206 ®Piping Sump/Trench Sensor(.). Model: 208 ❑Fill Sump Scnsor(s} Model ❑Fill Sump Sema(.). Madel: ®Mechanical Line Leak Detector Model: FX-2 ®Mechanical Line Leak Detector. Model FX-2 ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-Level Sense. Model: ❑Tank Oved-dl/IEgbd.evel Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 21 ❑Other(specify equipment type and model in Swum E on Page 2). TanklD 3 (DIESEL) Tank 11D: ®In-Tank Gauging Probe. Model: MAG2 ❑den-Tank Gauging Probe Model: ®Annular Space or Vault Sema. Madel:420 ❑Annular Space or Vault Sensor Model: ®Piping Sump/Trench Sensa(s). Model: 2W ❑Piping Sump/Trench Semor(s} Model: ❑Fill Sump Sonsa(s) Model: ❑Fill Sump Sema(.) Model: ®Mechanical Line Leak Detector. Model: FX-2 ❑Mechanecal Line Lesk Deta%or. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor- Model: ❑Other(specify equipment type and model in Section E on Page 2) ❑Otho(specify equipment type and model m Section E on Page 2). Dispenser ID: 1/2 D6pw ]D: 3/4 ❑DispenserContainment Sensa(s} Model: ❑Dispeua Containment Senaa(s). Model: ®Shear Valve(s) ®Shear VaW.) ®Dispenser Containment Float(s)and Cham(s). ®Disperser Co.-Float(.)and Cham(.) Dispenser ID Dispenser ID: ❑Dispenser Containment Sersona). Model: ❑DLspmxr Coeta®evt Semm(s). Model ❑Shear Valve(s) ❑Shear Vah*s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(.) Disposer ID DLvpeoaer ID: ❑Dispenser Containment Smaa(s) Model: ❑Dispenser Comainment Sensm(s) Model: ❑Shear Valve(s). ❑Shear Valve(.) ❑Dispenser Containment Float(s)and Chain(s). ❑Dispercer Containment Float(s)and Chmn(s). Yfthe facility commas more tanks or dispenses,copy this form. Include information for every tank and dicpensefat the facility. C. Certification -I certify that the equipment identified in this docmne nt was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information(e.g. manufacturers' checklists) necessary to verify that this infonration is correct and a Plot Plan showing the layout of monitoring equipmern. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that applj): ®System set-up ❑Alarm history Sepcurt Technician Name(print): Carl"Wayne"Henderson Signatureca,,..0 w- p Certification No.: 5252923-UT License.No.: 856771 Testing Company Name: HMC-Henderson Maint Co Phone No.:(209)467-7573 Site Address: 1405 Calif imia St-Esealon Date of Testing/Servicing: 7/11/2006 Page 1 of 3