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MONIT,QRING SYSTEM CERTIFICATION Fo e By All Jurisdictions Within the State of CMrnia Authority Cite& Chapter 6 7, Hea th and Safety Code; Chapter 16, Division 3, Tit e 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 Prepared 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 Name: SUPER STOP MANTECA Site Address: 290 N MAIN ST. City: MANTECA Bldg. No.: Zip: 95336 Facility Contact Person: BALDEV Contact Phone No.: ( 209 ) 239-4475 I Make/Model of Monitoring System: N/A Date of Testing/Servicing: %5/ ! / 0(o B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank lio- 87 Tank ID- ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular. Space or Vault Sensor. Model. ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99LD-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 r ype and model in Section E on Page 2). Tank ID• Tank ID• ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Tank Over -fill / High -Level Sensor. Model: Other(specify equipment and model in Section E on Page 2). Other(specify equipment 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- Dispenser ID - Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser ConiMment FlU5101and ChRM(NI. Dispenser Containmen oa s an ams . ispenser W- ❑ Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: ❑ Dispenser ID - Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Floats) and Chain(s). mispenser Containment Float(s) and Chain(s). • If the facility contains more tanks or dispensers. conv 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 wiih 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 history report Technician Name (print): NICK ADAMITZ Signature: NICK ADAMITZ Certification No.: Testing Company Name: West Star Environmental License. No.: 605142 Phone Number: (559)277-9378 Site Address: 4688 W. Jennifer Suite 101 / Fresno CA 93722 Date of Testing/Servicing: 05 / 09 / 06 Monitoring System Certification Page 1 of 4 03101