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MONI NG SYSTEM CERTIFI&TION - For se By All Jurisdictions Within the State of Cali o ma M H. // rr Authority Cited: Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code o �gula FbW �.;�,,�� This form must be used to document testing and servicing of monitoring equipment. A separate certification or renotf r i yd`b"acidhet,dach monitoring_ system control panel by the technician who performs the work. A copy of this form must be provided to th thn• ,44eiif 6o iA"r erator. 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: Super Stop Market Bldg. No.: Site Address: 290 N. Main City: Manteca Zip: 95336 Facility Contact Person: Kiran Jeet Make/Model of Monitoring System: EMC B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicates ecific equipment inspected/serviced: Contact Phone No.: (209) 239-4475 Date of Testing/Servicing: 3/26/2007 Tank ID: T-1 91 Tank ID: T-2 Diesel Z In -Tank Gauging Probe. Model: 847390-207 ® In -Tank Gauging Probe. Model: 847390-207 ® Annular Space or Vault Sensor. Model: 794390-420 Z Annular Space or Vault Sensor. Model: 794390-420 Z Piping Sump / Trench Sensor(s). Model: 0794380-208 Z Piping Sump / Trench Sensor(s). Model: 0794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: STP -MLD Z Mechanical Line Leak Detector. Model: 105989471 ❑ 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 87 Tank ID: ❑ In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model: 847390-207 Z Annular Space or Vault Sensor. Model: 794390-420 ❑ Annular Space or Vault Sensor. Model: Z Piping Sump / Trench Sensor(s). Model: 0794380-208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: LD -2200 ❑ 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 model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 3/4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Float(s) and Chain(s). Z Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Float(s) and Chain(s). Z Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). Z Dispenser Containment Float(s) and Chain(s). Z 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 inspected/serviced 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 equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ® System set-up ® Alarm histor` eport Technician Name (print): Gavin Williams Signature: A-, Certification No.: WIKT2074 License. No.: 05857 Testing Company Name: HMC- Henderson Maint Co Phone No.: (209) 467-7573 Site Address: PO Box 31325. Stoickton, CA 95213 Date of Testing/Servicing: 3/26/2007 Page 1 of 3