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From: Franzen -Hill Inc. To: 12094683433 Page: 3/5 Date: 1/20/2011 4:54:20 PM 0 0 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Piot Pian available at htto-ltwww.waterhoards.ca.gov.) MONITORING SYSTEM CERTIFICATION For Use By All Junsdictro»s Within the state of Csfi bmia Authority Cbed. Chapter &7, Health and Safdiy Cods, 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 prepared for each monitoring system control panel by the technician who performs the work. A copy of this form meet be provided to the tank system ownedoperator. The ownedoperator 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: ESCALON MINI MART Bldg. No.: Site Address: 1097 YOSEMITE N Faci ty Contact Person: BILL Contact Phone No.: MakelModel of MMftXirrg System:& rT K JR 4 Date of TestlnglServid 11 s. inventory of Equipment TestedlC*rtffded 'If the faminy Contains more tanks orampensers, Copy Ads Torn. UWKMa wtzvnnNUm ax UVW7 wase ww v o}meaw w vp ca...ny. C. C""ficathm - I certify that the equipment Identified in this docum6rit was hes iced 10 MDWIMOB with the mareullegua W guidelines. Attached to this Certification is hdforrmadan (e.g. manufacturers' checklists) necessary to verify that this Infanwillon is correct and a Piet Plan showing the layout of monitoring equipmtent; For squdpmwt of generating such reports, I have also attached a copy of the report: (check alt that a)rplgj: B System set-up E Alarm history report Technician Name (printy: ftRW Za n Slgnatwe: � Certification No.: _ _,4341047029 U ease. No.: Testing Company Name: Eamon jJ11 Phone No.:( §§2 _ )690-204 . Tea" Company Address: i i (A ne . r STAE,E.T TUIM CA 95 74 Date of TesftlServicing 1/10111 hton"Ang System certification Page t of 4 This fax was sent with GFI FAXmaker fax server. For more information, visit: http:/twww.gfi.com 1121W i Tenk KM. - Tank UY 0 - A7 _ular E In -Tank Gauging Probe. Model: 10.4 B In -Tank Gagbv Probe. Modal: E Annular Space or Vault Sensor. Model: 420, E Annular Space Of Vault Sensor. Madel: B Piping Sump I Trench Sensor{s). Model: 420 E Piping Sump I Trend Sensor(s). Model: E Fill Stump Sensor(s). Model: ja Fin Sump Sensor(s). Model: E Mechanical tine Leak Detector. Model: V Icy : E Mechanical Une Leak Detector. Model: B Eiectronic Lire Leak Detector. Mogi: E Electronic line Leak Detector. Madel: E Tank Om ill I High -Leve[ Sensor. Mogi: 480_ _-- E Tank Overfill d Sarson. Model: B Other (specify equt~ (M and model in Section E on Page 2). E Other apes aqui ty and model to Section E on Page . Tank ID: d2 .91 PromiUMTank E In -Tank Gauging Model: 122 10: B WTank Gauging Probe. Model: E Annular Soam Or Vault Sensor. Model: 42 E Annular Space or Vault Scram. Model: E Piping Sump I Trerch Sensor($). Model: 42a E Piping slump I T s). Model. R FIN Sump s). Model: E Fill Sensor(s). l: L mechanical Line Leak Detector. Madel: FE EMM E Mechanical Line Leak Detector. is E Electronic Line Leak Detector. Model: B Electronic Line Leak Detector. Model: E Tank Overfill I HWLevel Sensor. Model: E Tank Overfill 1 High -Level Sensor. Model: B Other (specify equipmerd type and model in Section E on Page 2). E Other (specify equipment type and model in Section E on Page 2). cftpmw ID: 9 2 Dispenser1D: 7 -8 B Dispenser Containment Sensor($). . Model. 42 B Dispenser Containment Sensor(s). Model: 4,70 B Shear Valves). E Shear Valu*). B Dispenm Containment Floats and Chai s . E glspenssr Containment Floe s and Chaim s . Dis ID: 1.4 Daper 1E3 E Dispenser Containment Seram(s). Model: AM E Dispenser Containment Sensor($). Model: E Shear Valve(s). B Shear Valve(s). E Dispenser Containment ELOs and Cha s). E Dispenser Containmeents and Chai s . Dispenser lD: 5 & Dispel' ID: B Dispenser Containment Sensor($). Model: 420 B Disperser Contakwwd Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). E Dispenser Containment I"($) and Chains E Disperser Cort Fktat(s) and Chains}. 'If the faminy Contains more tanks orampensers, Copy Ads Torn. UWKMa wtzvnnNUm ax UVW7 wase ww v o}meaw w vp ca...ny. C. C""ficathm - I certify that the equipment Identified in this docum6rit was hes iced 10 MDWIMOB with the mareullegua W guidelines. Attached to this Certification is hdforrmadan (e.g. manufacturers' checklists) necessary to verify that this Infanwillon is correct and a Piet Plan showing the layout of monitoring equipmtent; For squdpmwt of generating such reports, I have also attached a copy of the report: (check alt that a)rplgj: B System set-up E Alarm history report Technician Name (printy: ftRW Za n Slgnatwe: � Certification No.: _ _,4341047029 U ease. No.: Testing Company Name: Eamon jJ11 Phone No.:( §§2 _ )690-204 . Tea" Company Address: i i (A ne . r STAE,E.T TUIM CA 95 74 Date of TesftlServicing 1/10111 hton"Ang System certification Page t of 4 This fax was sent with GFI FAXmaker fax server. For more information, visit: http:/twww.gfi.com 1121W