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03-10-'11 09:40 FROM-West Star Envmt Inc, +559-277-0106 T-019 P0002/0006 F-807 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION For Use By All Judsdictfons Within the State of California Authority Cited:Chapter 6.7,Wealth and Safety Code;Chapter 16,Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepoired for each 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 location Super Stop Bldg.No.: Site Address: 290 N Main city, -Manteca Zip: 95336 Facuity Contact person: Mandeep Contact Phone No.:(209)239-4475_ MakelModel of Monitoring System:—emc Date of Testing/SetVicirlg:_3-8-11 B. Inventory of Equipment Tested/Certified Check the appro riate boxes to Indicate spegTg a ui ment ins ectedrserviced: Tank ID:#1 Prem.uni. Tank ID!_43 87 Reg unl In-Tank Gouging Probe. Model: In-Tank Gauging Probe. Model; __ _ Model: 420 x Annular Space or Vault Sensor. Motlel: 7_ 2 x Annular Space or Vault Sensor. M R P 208 x Piping Sum /Trench Sensor(s). Model: _x Piping Sump/Trench 5ensor(s). Modeh� i» g pFill Sump$ansor(s). Model! Fill Sump Sensor(s). Model:x Mechanical Line Leak Detector. Model: FE Petro _ _ X Mechanical Line leak Detector. Model: Electronic Llne Leak Detector. Model; ❑ Electronic Line Leak Detector. Model: _ 0 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: o Other(specify equipment and model in Section Eon Page 2}. 0 Others Ci a ui Ment a and model M Section I_on Pa 2. Tanic ib: 42 diesel. Tank ID: In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: x Annular Space or Vault Sensor, Model 420 ❑ Annular Space or Vault Sensor. Model: x Piping Sump I Trench Sensor(s). Model: 208 - _ 0 Piping Sump/Trench Sensor($). Model: Fill Sump Sensor(s). Model: ❑ f=ill Sump Sensor(s). Model: _.— x Mechanical Line Leak Detector. Model:—red jacket 11 Mechanical Line Leak Detector. Model; 0 T4nk Overfill/High-Level Sensor. Model: 0 Electronic line Leak Detector. Model: 0 Other(specify equipment type and model in Section E on Page 2). 0 Tank Overfill/High-Level Sensor. Model: ❑ Other,(specify equipment_sand model In Section E on Pa e 2). Olspenserlo: #11-2 -- Dispenser 10:#7-8 Dispenser Containment Sensor(s). Model- _ __ ...____ ❑ Dispenser Containment Sensor(s), Model: . to shear vaive(s). 0 $hear Valve(s). X Dis user Containment Float(s)and Chain(s). X Dis enser Containment Floats and Chafn s. glspensor 11):_#3-4 Dispenser ID: Dispenser Containment Sensor(s). Model.___,208_ 0 Dispenser Containmern Sensor(s). Model: 0 Shear Vatve(s). ❑ Shear Valve(s). rODispertser Dispenser Containment Floats and Chain(s). x Dis enser containment Floats and Chain s- ser ID: 5-6 Dlspensor ID: #11-12 Containment Sensor(s). Model: — ❑ Dispenser Containment Sensor(s). Model-0 Shear Valve(s). a enser Containment Floats and Chains x Dispenser Containment Floats and Chains. `If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C« Certification - I cartify that the equipment identified in this document was Inspectediserviced In accordance with the manufacturers` guidelines. Attaoi+ed 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 attached a copy of the report;(vheck all that apply): a system set-up ❑Alar history report Technician Name(print): James(tom)Wall $ignature: _)a Axa Certification No.: 8029369 License.No.: 605142 Testing Company Name:West Star environmenlaf Phone No.:L,959, 277-9378 Testing Company Address: 6888 W JeAnifer Fresno ca 93722 Hate of Testing/Servicing: 3-8-11..-. Monitoring system Certification Page 1 of 4 1 2/21/07