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ONI NG SYSTEM CII TIONGECEN 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 Co4h This form must be used to document testing and servicing of monitoring equipment. A§Marate certification or re 9161monitoring y t _sem control panel by the technician who performs the work. A copy of this form must be , / em owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems withit{ d A. General Information Facility Name: Super Stop Market Bldg.No.: Site Address: 290 N. Main City: Manteca Zip: 95336 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: EMC Date of Testing/Servicing: 5/27/2009 B. Inventory of Equipment Tested/Certified Check the apgropriate boxes to indicatespecific a ai ment inspected/serviced: Tank ID: T-1 87 Tank ID: T-2 91 ®In-Tank Gauging Probe. Model: VR ®In-Tank Gauging Probe. Model: VR ®Annular Space or Vault Sensor. Model: 420 ®Annular Space or Vault Sensor. Model: 420 ®Piping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: LD-2000 ®Mechanical Line Leak Detector. Model: FE Petro ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: T-3 Diesel Tank ID: ®In-Tank Gauging Probe. Model: VR ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 208 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: RX ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and andel in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser' Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 1/2 Diesel Dispenser ID: 3/4 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ®Shear Valve(s). ®Shear Valve(s). ®Dispenser Containment Float(s)and Chain(s). ®Dispenser Containment Floags)and Chain(s). Dispenser ID: 5/6 Diesel Dispenser ID: 7/8&9/10 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model- 0 Shear Valve(s). ®Shear Valve(s). ®Dispenser Containment Float(s)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 ins 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 egai men". Foe any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): stem set-up Alarm history report Technician Name Gavin William Signature: Certification No.: 8016288-UT License.No.: M6771 Testing Company Name: HMC-Henderson Maintenance Company Phone No.:(209) 467-7573 Site Address: Date of Testing/Servicing: 5/27/2009 Page 1 of 3