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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Piot Plan available at hitp:llwww.waterboards.ca.aov.) MONITORING SYSTEM CERTIFICATION For Use By AH Jurisdictions Within the State of Califomia 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 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 ownerloperator. The ownerloperator must submit a copy of this forth to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Eascalon Mini Mart Bldg. No.: Site Address: 1097 E Yosemite City: Escalon Zip: 95320 Facility Contact Person: Contact Phone No.: ( 209 ) 838-1546 MakelModei of Monitoring System: Autostik Date of TestinglServicing: 12 114 12010 B. Inventory of Equipment TestedlCertified r`hadr fho annMnriata hnxaa fn indiraYa nnar_iNr_ anidnmant Inanartarilacruirad- Tank ID: # - 87 Regular Tank ID13 - E in -Tank Gauging Probe. Model: 109 E in -Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Modes: LS -3A E Annular Space or Vault Sensor. Model: E Piping Sump I Trench Sensor(s). Model. LS -3A E Piping Sump I Trench Sensor(s). Model: E Fill Sump Sensor(s). Model: E Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: FE Petro E Mechanical Line Leak Detector. Model: E Electronic Line Leak Detector. Model: E Electronic Line Leak Detector. Model: E Tank Overfill I High -Level Sensor. Model: flap E Tank Overfill I High -Level Sensor. Model: E Other (specify equipment type and model in Section E on Page 2). B Other (specify equipment type and model in Section E on Page 2). Tank ID: 02 - 91 Premium Tank ID: E In -Tank Gauging Probe. Model: 109 E In -Tank Gauging Probe. Model: E Annular Space or Vaud Sensor. Model: LS -3A E Annular Space or Vault Sensor. Model: E Piping Sump I Trench Sensor(s). Model: LS -3A E Piping Sump I Trench Sensor(s). Model: E Fill Sump Sensor(s). Model: E Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: FE Petro E Mechanical Line Leak Detector. Model: E Electronic Lina Leak Detector. Model: E Electronic Line Leak Detector. Model: E Tank Overfill I High -Level Sensor. Model: flap E Tank Overfill I High -Level Sensor. Model. E Ogler (specify equipment type and model in Section E on Page 2). E Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 7-8 E Dispenser Containment Sensor(s). Model: LS -3A E Dispenser Containment Sensor(s). Model: LS -3A E ShearValve(s). E Shear Valve(s). E Dispenser Containment Floats and Chain(s). B Dispenser Containment Floats and Chatn(s). Dispenser ID: 3 - 4 Dispenser ID: E Dispenser Containment Sensor(s). Model: LS -3A E Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). E Dispenser Containment Float(s) and Chain(s). E Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5 - 8 Dispenser ID: E Dispenser Containment Sensor(s). Model: LS -3A E Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Velve(s). E Dispenser Containment Float(s) and Chain(s E Dispenser Containment Floats) and Chain(s). it the Tawny comains more tanks or amperisers, copy mis Corm. mcivae information for every tank and dispenser at the facility. C. Certification - i certify that the equipment Identified In this document was Inspectediserviced 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): E System set-up E Al history report Technician Name (print): Stephen Zwahlen Signature: Certification No.: _4341047029 License. No.: 0304147 4 n Testing Company Name: Franzen Hill Phone No.:(( j (pq►� a�'1 �, Testing Company Address. 1100 N J St Tulare. CA93274 Date of TestinglServicing: 12 114 1 10 Monitoring System certification Page 1 of 4 12W `� RQ,�QC}eat d�u. +10 no rW+). i CA+ 10✓�