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NOV-28-2012 17:33 From: 2098254549 To:4683433 Pase:9�11 Appendix VI (Copies of Monitonng System Certification form and UST Monitoring Plot Plan available at ht�/lwww waterbo dti ,4glS•) MONITORING SYSTEM CERTIFICATION For Use By All Junsdicums,Within the State Of Cain M;a Authority Cited. Chapter 6.7, Health and Safety Code;Chapter 16,Division 3, TiNe 23, California Code of Regulations This torn must be used to document testing and seryiomg of monitoring equipment A separate certification Of report must be prepared for each monitoring system control Panel by the technician who performs the work. A ropy 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:. OUICKI KLEEN •_ _ Bldg.No.: Site Address: 70T YOSEMITE AVE City: MANiECA Zip- Facldty Contact Person: FRANr'ENE ESCABAR _ Contact Pndne No.'( _209 814,3726 Make/Model of Mnrktonng System: S 35o Date of Teeting/Sen ong:^71 1_14_/ 2012 B. Inventory of Equipment Tested)Certined Ctteok the a nate boxes to indicate is ific ui ent ins serviced: Tank ID:TAKK 1 SOIfrH 10 K REG UNI Tank ID; DIESEL -- X In-Ta MUM Gauging Probe. Model:•Mg, � X In-Tank Gauging Probe. Model- t X Annular Space m vault Sensor. Madel: V1 08 X Annular Space or Vault Sensor. ModeV.. V/R 408 X Piping Situp!Trench Sensor(s)- Model. Y/R 208 X Piping Sump/Trent,Settsor(e)• Model _ V/R 208 X Fie.sump Serine L)- Model:SAME X Fill Sum Sense s. X Mechanical Lire Leak Detector. Model _ P K ) Model: !i1 taeamnic Line Leak Detector- X Mechanical Line Leak Detector. Model: ` Model: C Electronic Line Leak 17e(edar. me". Tank Overfill/High{.meal Sensor. Model: D Tank Overfill/High-Level Sensor, Modal: X Other s t and model in Section E on 2. X Other a Tank Ip;TANK-,;*Jetl SK R� I1NL _ . and motlH in Secepn E on Pe X In-Tank Gauging Probe. �� T'ank ID: rr9 Model: MAGA D LIVT9nk Gauging Preoe. Modgt: --. X Annular Sump I or Vaunt Sensor. Model: V/R 908 D Annular S X Piping Sump/bench 5erutortsl. Model: VA2 Zoe �` Pace or Vault Snsot(5 Model: x Me Sump l LimSericar(s).Lea Model, E ,-.- D Piping Sump r or(s) Sensor(s). Model: X Mechanical Line Leak Detector. Model: D Ma Sump Sarno Lea Mode: Electronic Line Leak Detector. � Merlearxeal Line Leak Detector. Model: - Tank Overfill/Hi h• Model- D Electronic Lino Leak Detector. Modek X Others 9- merit$erlaor. model: 1, Tank Overfill/High-Level Sensor, Meloy: and model in Secbon E on pa 2. ❑ Dther u meet arrcf model in Section E on APage . Dlsperrser IP. 112 Dispenser lb: 7 X DQperrser Cgntammem Servor(s). Medd: X Shear VaNe(sl_ —3,08 x Dispenser Comainmem Serrsor(s). Model: 20a Dns arrear Containment Flo sand Chains. X Smear VaNa(s). _ ❑ Di er�er Containmem Fpatfs)and Ghain(s). Dispenser ID: 3/4 Drspensor ID: X Dispenser Comartmem Ser,sor(s).Mmei: 208 - Dispenser Cpmammem Senso X Shear vsNe(sl- r(s). Model: [. ons user CAmainment Floats anti Chains. :- Shear VaNe(s). C. D' user Containment Floats and Chain(s). Olapensar l0: s/8 - - Utalxerlsarl6 X D�penser Gontawnem Sensor(s)- Model: 208 x Shear VaNe(s). = Dispenser Containment Sensor(s). Modes nd Cha �_ Dns riser C4mahrmeM Fbat s and Crain s -' Shear Valve(s). "tithe faality contains more larks pr dispensers,cpPY this form. Induce infdrmstion for every tank amt d parser at the fadlky.a C. CertificaHen - 1 certHy mat Ne equipment idanUflee in thin documerH was Ing guidebnes. ACaened ro th{s CardHcatlen.s ImornnaHprr g. PeetM/servieed in aeeordartce with the manufaehren:' and a Plat Pym showing me layem of monitor7ng equipment For anyy equipmentcktpa i oc ^J m vedfy that this infunnadon Is correct copy of the mparg(check all that apply): _,Spsbm setwp Alam1 history generating such rupgrts,I have alto attached a Technician Name(prim): GREE;KAISER___ Signahrre: Cadifimtlon No _ A25983 I.ict'itse,No.: 6 Testing company Name: 1 COMMERCIAL PETROLEUM one NO L-209—)--401 2379 Testing Company Address 331 NEWI RD U EN 9 Date trf TestinglServicing:_11_/_74_1 2012_ Monitoring System Certification Page t of a 72107 1 2/21/07