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Aug Is 03 10: 13P Char•i t;j Miles (209 ) 533-2050 P. 1 <br /> 0 <br /> All 1,e.,c <br /> 17759 Buttercup Circle, Sonora, CA 953701 <br /> Phone: 209-532-7320; Fax: 209-533-2650 <br /> a•;1`, <br /> California Contractor 623541 A-Haz <br /> alltech@Zgetrocket.corn <br /> MONITORING SYSTEM CERTIFICATION <br /> A. General Information <br /> Facility Name: Madsen's Sunrise Dairy Date of Testing/Servicing: August 19,2003 <br /> Facility Address: 239 S. Stockton St.,Ripon CA 95358 <br /> Facility Contact Person: Bob Madsen Contact Phone No.: 599-3041 <br /> Make/Model of Monitoring System: Incon 1000 <br /> B. Inventory of Equipment Tested/Certified: <br /> Tank ID:Regular Compartment Tank ID:Premium Compartment <br /> ❑In-Tank Gauging Probe. Model:None ❑In-Tank Gauging Probe. Model:None <br /> N Annular Space or Vault Sensor. Model:Optical sensor N Annular Space or Vault Sensor. Model:Shared w/87 <br /> ❑Piping Sump/Trench Sensor(s), Model:None 1 ❑Piping Sump/Trench Scnsor(s). Model:None <br /> ❑Fill Sump Sensor(s). Model:None ❑Fill Sump Sensor(s), Model:None <br /> Mechanical Line Leak Detector. Model:None ❑Mechanical Line Leak Detector. Model:None <br /> ❑Electronic Line Leak Detector. Model:None ❑Electronic Line Leak Detector. Model:None <br /> N Tank Overfill/High-Level Sensor. Model:Drop Tubes N Tank Overfill/High-Level Sensor. Model:Drop Tube <br /> ❑Other ❑Other <br /> Tank ID:Diesel Compartment Tank ID: <br /> ❑In-Tank Gauging Probe. Model:None ❑In-Tank Gauging Probe. Model: <br /> N Annular Space or Vault Sensor. Model:Shared w/87 ❑Annular Space or Vault Sensor, Model: <br /> ❑Piping Sump/Trench Sensor(s). Model:None ❑Piping Sump/Trench Sensor(s). Model: <br /> ❑Fill Sump Sensor(s). Model:None ❑Fill Sump Sensor(s). Model: <br /> ❑Mechanical Line Leak Detector. Model:None ❑Mechanical Line Leak Detector. Model: <br /> Electronic Line Leak Detector. Model:None ❑Electronic Line Leak Detector. Model: <br /> ®Tank Overfill/High-Level Sensor. Model:Drop Tube ❑Tank Overfill/High-Level Sensor. Model: <br /> i ❑Other ❑Other <br /> Dispenser ID: I N Sump:0Dry El Water❑Product Dispenser ID:2 M Sump:®Dry❑Water❑ProduiK <br /> N Dispenser Containment Sensor(s). Model.Float Switch N Dispenser Containment Sensor(s). Model.Float Sw. <br /> Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) <br /> Q Dispenser Containment Float(s)and Chain(s). _ ❑Dispenser Containment Float s)and Chain(s). <br /> Dispenser ID:3® Sump:®Dry❑Water E❑1'roduct Dispenser ID: ❑ Sump:❑Dry❑Water❑Product <br /> N Dispenser Containment Sensor(s), Model:Float Sw. ❑Dispenser Containment Sensor(s). Model: <br /> ❑Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) <br /> ❑Dis enser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: ❑ Sump:[]Dry[I Water❑Product Dispenser ID: ❑Sump:❑Dry❑Water❑Pr(AUCL <br /> ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model. <br /> ❑Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) <br /> ❑Dispenser Containment Floats and Chain(s). ❑Dis nser Containment Flogsl and Chains . <br /> C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the <br /> manufactarers' guidelines. Attached to this Certification is information(e.g. manufacturers'checklists) necessary to verify that this <br /> information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such <br /> reports,I have also attached a copy of the report; (check all that apply): ❑System set-up ❑ Alarm history report <br /> Technician: !''!/k pwew Mike Dotten,California Contractor License.No.: 623541 - <br /> Certification: I n eon: <br /> Page 1 of 3 03101 <br />