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GaL EQUIPMENT SERV STATE LICENSE No.323417 CLASSIFICATION: A-HAZ.,C61D40 Division of Keith A. Tallia, Inc. STATE ENVIRONMENTAL ASSESSOR No.01791 Telephone: (209)754-1808 Fax: (209)754-5726 Post Office Box 950 750 Industrial Way SAN ANDREAS,CALIFORNIA 95249 MONITORING SYSTEM CERTIFICATION '['his form must be used to document testing and Servicing of moniloring equiprcnt. If more than one monitoring system control panel is installed at the facility, a separate certification or report must be prepared for each monitoring system control enol 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[his form to the local agency regulating UST systems within 30 days of-test date" Instructions are printed on the back of this page. A. General Information Facility Name: Three Palms Grocery Bldg. No.: Site Address: 6732 E. Waterloo Rd. City: Stockton Zip: 95215 Facility Contact Person: Rudy Contact Phone No.: ( 209 ) 931 -6048 - Make/Model of Monitoring System: INCON TS1001 /Ronan X76 Date of Testing/Servicing: 11 /21 /02 AST-4X-2 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 1 Regular Tank ID: 2 Plus U In-Tank Gauging Probe. Model: Senqnr ❑ In-Tank Gauging Probe. Model: seaaQx- 0 Annular Space or Vault Sensor. Modcl:Ronan Sumpl lZ Annular Space or Vault Sensor. Model: Ronan Sump/ 0 Piping Sumpfl'rench Sernsor(s). Model:Ronan Gtmmp/ _ to Piping Sumprrmnch Sensor(s). Model: Ronan Sump I ❑ Fill Sump Sensor(s). Model: Sensor ❑ Fill SumpSensor(s). Model: Sensor CI Mechanical Line Leak Detector. Model: 13 Mechanical Line Leak Detector. Model: U Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: N Tank Overfill/High-Level Sensor. Modcl:OPW 61 SOP (21 Tank Overfill/High-Level Sensor. Model: OPW 1 SOP N Dispenser Containment Sensor(s). Model:T PP ULS 11 Dispenser Containment Sensor(s). Model: TrSP ULS U Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). El Other(smify equipment type and model in Section E on Page 2). O Other(specify ui ment type and model in Section E on Page 2). -' Tank ID: Tank ID: O In-Tank Gauging Probe. Model: _ 0 In-Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: ❑ Piping Sumphrrench Sensor(s). Model: _ U Piping SumprTrench Sensor(s). Model: U Fill Sump Sensor(s). Model: Cl Fill Sump Sensor(s). Model: _ U Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: _ ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: _ U Tank Overfill/High-Level Sensor. Model: _ l7 Tank Overfill/High-Level Sensor. Model CI _ Dispenser Containment Sensor(s) Model: _ U Dispenser Containment Sensor(s). Model i O Shear Valve(s). U Shear Vah-e(s), O Dispenser Containment Floats)and Cham(s). U Dispenser Containment Float(s)and Char(s). O Other(specify ui ment Iv rc and model in Section E on Page 2). U Other is ecifv equipment and model in Section E on Page 2). C. Certification - 1 certify that the equipment identified in this document was inspected/serviced in accordance with (he manufacturers' guidelines. Attached to this Cerlificali0u is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Site Plan showing lite lavout of monitoring equipment. For any equipment " capable or generating surh t qm,ts. I (rave also attached :t cnpc al the Wheeh Wt that apphr): U System ;et up repnrl: U Alarut hismry re 1. Teclutician Name(prim). James P Heske#h—.--_ Cep./Lie. Nu. 6-116.69 -- Signature: .-. _ testing Company Name _ Oil Equipment-Service. . --- Phonr No- ( 2 )754-1 808 ..