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17759 Buttercup Circle, Sonora, CA 95370 Phone: 209-532-7320, Fax: 209-533-2650 ER : California Tank Tester: 90-1068 ' California Contractor 623541 A-rtNaz alltec mlode.com MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Madsen Sunrise Dairy Date of'Festing/Servicing: June 21, 2002 Facility Address: 239 S. Stockton St.,Ripon CA 95358 Facility Contact Person: Bob Madsen Contact Phone No.: 599-3441 Make/Model of Monitoring System: Incon 1000 B. Inventory of Equipment Tested/Certified: M Multi-compartment tank;® Single annular sensor. Check theappropriate boxes to indicates cific equipment ins tedlserviced: Pass ❑Fail f 'tank ID:Regular Comparlment Tank ID:Supreme Compartment ❑In-Tank Gauging Probe. Model: ❑la-Tank(_iauging Probe. Model: Annular Space or Vault Sensor, Model.Optical(Shared) M Annular Space or Vault Sensor. Model:Shared ❑Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Seosor(s). model: ❑Fill Sump Sensorls). Model: ❑Mechavic:al bine Leak Detector. Model: ❑Mechanical Linc Leak Detector. Model: ❑F lc-tropic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: " M Tank Overfill f High-Level Sensor. Model:Balltloat ❑Tank Overfill/High-Level Sensor. Model: El Other _ ❑Other `rank ID:Diesel Compartmrnt Tank 10: ❑hi-Tank Gauging Probe. Model: ❑In-Tank Gauging Yrobc. Model: M Annular Space or Vault Sensor. Model:Shared ❑Annular Space or Vault Sensor. model- ❑Piping Sump/Trench Sensor(s). Model: ❑Piping Sump VI rcnch Scnsor(s). Model: ❑FiI I Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑I-Ilcctronic Line Leak Detector. Model: ❑"Tank Overfill! High-lxAvcI Sensor_ Model: ❑Tank Overfill/ High-level Sensor. Model: t)thcr ❑Other _ Dispenser ID: Regular M Sump:9Dry❑Water❑Product Dispenser ID: Supreme M Sump:Mlhy El Water❑Product ®Dispenser Cortainme.nt 5errsor(s). Model:Float Sw, M I)ispenser('ontainmerrt Sensor(s). Modcl:Float Sw. ❑Shear Valve(s) (Functional test) ❑Shear Valve(s) (f unc:lional test) ❑Dispenser Containment Float(s)and Chain(s)_ ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Diesel M Sump:ODry❑Water❑Product Dispenser tD: ❑ Sump:❑Dry❑Water❑Product M Dispenser Containment Sensor(s). Model:Float Sw. ❑Dispenser Containment Sensor(s). Model: ❑Shear Valvc(s) (Functional test) ❑Shear Valve(s) (Functional test) !, ❑ ?i enSer Containmant Float(s)and Chain(s). ❑Dispenser Contaiitment Float(s)and Chain(s)_ — r Dispenser ID: C] Sump:❑Dry❑Water❑Product Dispenser ID: ❑ Sump:[I Dry L1 Water❑Product— ❑Dispenser Containment Sensor(s). Model: ❑Dispenser('ontairimeni Sensor(s). Model: i ❑Shear Valve(s) (Functional test) El Shear Valves) (Functional test) ❑Dispenser Containment FI 2iti-9 and Chains- 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 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,t have also attached a copy of the report; (check afi that apply): ❑ System set-up ❑ Alarm history report Technician: Adiz:_ !Mike Dotten, California Tank Tester License. No.: 90-1068 Certification: Veeder-Root: 34t-32-6743; Level 3. Page I of 3 03101