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07)23/201311:53 : (209)485-4905 MaryAnn Henderson REC"EIVED • MONITORING SYSTEM CERTIFICATION JUL 2 3 2013 For Use By All Jurisdictions Within the State of California Authority Cited.'Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23, California Code o s f � This form mast be used to document testing and servicing of monitoring equipment.A sweirate certification or report must Hct ar7-+a I NTAL MENT monitoring system control panel by the technician who performs the work. A copy of this form must be 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 Facility Name: KWiK SERV Bldg.No.: Site Address: 824 E YOSEMITE City: MANTECA Zip: 95336 Facility Contact Person: MGR Contact Phone No.: ( ) Make/Model of Monitoring System:EMC Date of Testing/Servicing:6/2812013 B. Inventory of Equipment Tested/Certified Chedtthea ro tdatehorq to itriirate c ai ent ltu cted/setviced: Tank ID: REGULAR Tank ID: PLUS ❑In Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 420 N Amrular Space or Vault Sensor. Madel: 420 ®Piping Sump/Trench Senwr(s). Model: 205 NPipmg Sump/Trench Scraoi(s). Model: 206 ❑Fill Sump Smsor(s). Model: ❑Fill Sump Sensor($). Model: ®Mechanical Linc Leak Detector. Model: LD 2000 N Mechanical Line Leak Detector. Model: LD2000 ❑Electronic Line Leak Detector. Modeh ❑Electronic line Leak Detector. Model: N Tank Overfill/High-Level Sensor. Model: FLAPPER N Tank Overfill/High Leval Seneor. Model: FLAPPER ❑Other(sp&*equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). TankiD: SUPREME Tank IN ED In-Tank Gauging Probe. Model; ❑In-Tank Gauging Probe. Model; ®Annular Space or Vault Season. Model: 420 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Scosor(s} Model: 205 ❑Piping Sump/Trench Srnsor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Saisor(s). Model: ®Mechanical Line Leak Detector. Model; LD 2000 ❑Mechanical Line Leak Detector. Madel: ❑Electronic Line Leak Detector. Madel: ❑Electronic Line Leak Detector. Model: N Tank Overfill/High-Level am= Model. FLAPPER ❑Tank Overfill I High-Level Sennas. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and mode]in Section E on Page 2). Dispenser ID: 112 Dispenser ID: 3/4 N Dispenser Cordairomm:Scumirfs). Model: 208 ®Dispenser Comainmert Sensor($). Mode(: 2W ®Shear Valve(s). N Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s) ❑Dispenser Conlairunent Float(s)and Chain(s). Dispenser ID: 516 Dispenser ID: 718 N Dispenser Containment Sensot(s). Model: 208 N Dispcmer Comammeat Semor(s), Model: 208 ®Shear Valve($), N Shear Valve(s). ❑Dispcu CmtairmaatRod(s)acrd Chain(s). ❑DlspeneerContnimnenrflom(s)and Cham(g). Dispenser ID: Dispenser ID: ❑Duspenscr Containment Seasor(s) Model: ❑Dispenser Containment Sertsor(s). Model: ❑Shear Valve(s). ❑Shcarvalve(s). ❑Dispenser Containment Float(a)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). *If the facility contains more 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 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,I have also attacbed a copy of the report;(check all that apply): E System Set-,— E Alarm history report Technician Name Charles Ferrucci Signature: Certification No.: 637512 License; No,. 96252 Testing Company Name: Service Staion Testing, Inc. Phone No.:(209) 4655577 Testing Company Address: PO Box 31465 Stockton,Ca 95213 Date of Testing/Servicing:6128/2013 Page 1 of 3 Rev(2/08)