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MONIORING SYSTEM CERTIFIWTION For Use By All Jurisdictions Within the Skate of California Authority Cited,Chapter 6.7, Health 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 certifie�ation or report must�e orenared nr each moniin system contmi 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. Genera(Information Facility Name. ESCALON MINI MART Bldg.No.: Site Address: 1097 E.YOSEMITE City: ESCALON Zip: 95320 Facility Contact Person: BILL Contact Phone No.: (209) 633-1546 Make/Model of Monitoring System: EBW Auto/Stik Jr.4 Date of TestftWServicing: 11/25/2009 B. Inventory of Equipment Teste&Certi£ed Check the.appropriate boxes to Indicates ecilie equipment ine ectad/serviced: TankiD: Unleaded TanklD: Premium Tn-Tank Gauging Probe. Model: 960 ®In-Tank Gauging Probe, Model: 960 (�Annular Space or Vault Sensor. Model: LSSA ®Annular Space or Vault Sensor. Model: LSSA ®Piping Sump/Trench Sensor(s), Model: LS3A ®Piping Sump/Trench Scttsor(s), Model: L33A ❑Fill Sump Scnsor(s). Model: Q Fill Sump Sensor(s). Model: ®Mechanical Linc Leak Detector. Model: VAPORLESS 0 Mechanical Linc Leak Dctcctor, Model: RED JACKET ❑Electronic Line Leak l3acctor. Model: ❑Electronic Line Leak Detector, Model: ®Tank Overfill/High-Level Sensor. Model: OPW61SOEVR ®Tank Overfill/High-Level Sensor. Model: OPWGISOEVR ❑Other(specify equipment type and model in Section E on Page 2). ElOther u (specify equipment type and model in Section]?on Page 7). Tank iD: Tank Ili}: ®In-Tank Gauging Probe. Model: ❑in-Tank Gauging probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Anular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model: []Piping Sump/Trench Sensor(s). Madel: Fiil Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Linc Leak Detector. Model: Q Electronic Line Lcak Detector. Model: ❑Tank Overfill 1 High-Level Sensor. Model: [3 Tank Overfill/High-Level Sensor, Model: Other(specify equipment typc and model in Section E on Page 2). Q Others i' (pec'fy equipment type and model in Section E an Page 2), Dlgnnser ID: 1/2 Dispenser ID: 314 ®Dispenser Containment Sensor(s). Model: LS3A 0 Dispenser Containment Sensor(s). Model: L33A Shcar Valve(s). ®Shear Valve(s). rDispemer er Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). iD: 5/6 Dispenser iD: 7/8 er Containment Sensor(a). Model: LS3A ®Dispenser Containment Scnwr(s). Model: L33A alve(s). ®Shear Valve(s). r ConminmenL Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chein(s). Dispenser 10: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sense*). Model: ❑Shear Valve(s). ❑Shear Vatvc(s). ❑Dispenser Containment Moat(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 inspectedlserviced in accordance with the manufacturers' guidelines. Attached to this Certification is Information (e.g. Manufacturers' cheddlSts) ttecessa verify that this Information Is correct and a Plot Plan showing the layout of monitoring nlpment. For any equipment capable generating such reports,I have also attached a copy of the report;(check aU that apply): System set-up ® "he report Technician Warne(print): Junlor Sint e Signature: Certification No.: 122621376 License,No.: "4147 Testing Company Name: Franzen-Hill Phone No.:1559 688-2977 Site Address: 1100 N. /0J"St.Tulare 93274 Date;of Testing/Servicing. 11/25/2009 Page 1 of 3