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MONITORING SYSTEM CERTIFICATION MAY 0 4 2016
<br /> For['se By All Jurisdiiuurrs if`ilhin lire Smit,ql California
<br /> AW1j1 ��*.*Apr�
<br /> f urhoray('iced:Clruprrr 6.7.Meulih enrd Scrfelt'C rwh-Claepier 16,Divis€on 3. Dile 23.C alrforma Code af,1,,,l Z t I.* _Ap_r r
<br /> Fhis form must be used to document testing and servicing of monitoring equipn€er€t.A,:Wdot�ysrtifis OtiUfl..t?[report must he prepared for each monitorine
<br /> s�'stem cunir,k Dane l by the technician who performs the€N,,rkL A copy of 1hit,form must be prnvidcd to the tank system u"ucrloperator. The uwncrloperator
<br /> must submit a eopyof this town to ilre local;,gene) regulating('S'r s)sterns u ilhin 30 days of test date.
<br /> A. General Information
<br /> Facility Nome: COUNTRY MARKET PLACECounty: SAC JOAQUIN
<br /> Site Address: 1789 W CIIARTER WAY City: STOCKTON
<br /> Facility Contact Person: HARP GILL _ Contact Phone 209-941-2222
<br /> Make/Model of Monitoring S�;It;m: "CLS350 Date of"Testinv Servicing: 3/8/2016
<br /> B. Inventor• of Equiptnent Tester')/Certified _
<br /> Tank ID: 87 '- —�� "Tank 11): 91
<br /> ® In-Tank(ial ging Mobe. ,d:l MAG" ®lnJank C,auemg Probe !Model NIAG
<br /> ®Annular Space or Vault Senior. M,dc1 420 T ®Annular Space or Vault Sensor. Modic, 420
<br /> ® Piping,Sump!Trench Sensor(s). Model 208 ®Piping Sunip l"Trench Sensor(s). Model: 208
<br /> Cl Fill Sulnp Svnsor(s). Model ❑Fill Sump sensor(s). 'Model.
<br /> ®Mechanical Line Leak Detector, Mode!' L.D2000 ®Mechanical I.ine Leak Detector Model F;\11'
<br /> ❑ Electronic I.,ne Leal Dcwctor. !Model: ❑Electrcn<ic i,inc Lents Detector. 1Mudcl
<br /> ® I'ank Chrrlill;I %I W ®'I auk(t,eriiil l High-f.c,cl Sensor Modcl. MAC
<br /> ©Other(specuy eyuipn€c:al L)pe and nio&l€n Sc�ukm r on Pigc 2). ❑Other(,pdeily equipment type and model in Section E on Page 2).
<br /> Tank ID: s �i Ttlnk ID
<br /> ❑In-Tani,Cuugirtg Probe. Mod I _ ❑ III-TUN,(,auging Probe. Model
<br /> ❑Annular Space of Vault Sensor t cidel ❑.Annular tipacc or Vault Sensor. '+Model,
<br /> ❑Piping Sump/'French Sensor(s). Model [❑ Piping.Sump i Trench Sensor(s) Madel.
<br /> ©Fill Sump Sensor(s) Model, ❑ Fill Sump Scnsur(s) Model:
<br /> ❑Mechanical tine leak Detector. Model ❑ Mechnuical I ine Leak Detector. tti1odel:
<br /> ❑Electrunit I.ine I cal,Deteclor Model j © ElecireniL Line Leak Detector. Model'
<br /> ❑Tank Usrrlill'I ligh-L,;%e€Senior. .`Iodci ❑"tank(.),erhll I Higli-Level Sensur Model.
<br /> ❑(Xher[spec€ly tquipihchi i4pc and ni,klel in Section i_oi�11age 2) ❑Other(spccik cquipi-noit type and model in Section F ou Page 2).
<br /> Dispenser JD: 1;2 _ Dispenser It): 314
<br /> ®Dispenser 1lntai€trrtent Sensor(.$)- V!.drt 001 ®I)ispemcr'Cun[ainrttcnl Sensor(s). Modcl. 001
<br /> ®')hear\alVVIs)- — ®Shear s'alvct,l
<br /> ❑ Dispenser C ontainment PIDat(s)and Chains) ❑Dispen,er Containthent Float(s)and Cham(s).
<br /> Dispenser ID: S16 � Dispenser 11) 718
<br /> ® DispenserCuntuinniciaJcr,utls). �+•,J,i Oil ❑ Dispsn,.r(ouammentSensorls). Model (101
<br /> ®Shear Valid.,) Shear 1,a')+e(,1
<br /> ❑Dispenser C untanuna,t 11cu(st aitd c haoi,�i ❑ Dispenser Containment How(,$)and Chnin(s).
<br /> Dispenser Ill: )l10 Dispenser ID: 11/12
<br /> ®Dispen,cr C'ontai:u3ttltt S.i.zUi(d) 'V101Icl 001 ® Dispen,c• izontainmcnt Sensor(s). Model: 001
<br /> ®Shear Vaiv.(,), (� Shcar valvc(s).
<br /> ❑Dispe€rser C-untartn,rrt l Ixu(s l and C.ai n S3. 9 ❑ Dispemcr Conlainnnni Flost(s)and Chain(sl.
<br /> Check the apprupri:.te buses I i€€dicale specilic equipment Iuspeerrd'scr,iecd:
<br /> C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the
<br /> manulacturers' guidelines. Attached to this Certification is information (e.g, manufacturers' checklists) necessary to verify that
<br /> this Inrurnmi:uji is curreet and a Phan showing the layout ur inunitoring equipment. For any equipment capable of generating such
<br /> reports,I have also attached a copy ofthe report;{check all ilial apply): Z System set-o ® 1[Strttt histor report
<br /> Technician Name(print): DAVID ROUSE Signature: _f _-
<br /> Certification B44848i icatlse No.: 33
<br /> ng159
<br /> TestiCuinpmi N:4€II:: _ B. G. Service Station Maintenallce Hione No.: (916) 311-2380
<br /> Site 1041 Triuu le Court West Sacramento,CA H:560fi_ Date ol"I esting,Servicing: 3/8/2016
<br /> Monitorial–,Certihcattull i est R1:i)0r1
<br /> I of 4
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