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It ®NIT SYSTEM CERTIFI ION For se By All Jurisdictions Within the State of Califor7ra Authority Cited.-- Chapter 6.7, Health and Safely 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 copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of ihls'fntm t0 i regulating UST systems within 30 days of test date. A. General Information Facility Name: Site Address: ESCALON MINI MART % Facility Contact Person: BILL Make/Model of Monitoring System: AUTOSTICK JR4 B. Inventory of Equipment Tested/Certified Check the aunronriate boxes to indicate specific equipment impeetedlserviceds; City: f=SCALON Contact Phone No.: (209) 838-1546 Date of Testing/Servicing: 1127/2016 Tank ID: 87 Tank ID: 91 ® In Tank Gauging Probe. Model: AUTO STICK ® In -Tank Gauging Probe. Model: AUTO STICK ® Annular Space or Vault Sensor. Model: ULS ® Annular Space or Vault Sensor. Model: ULS ® Piping Sump / Trench Sensor(s). Model: ULS ® Piping Sump / Trench Sensor(s). Model: ULS, ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: (� Mechanical Line Leak Detector. Model: RED -JACKET N Mechanical Line Leak Detector_ Model: REDJACKET ❑ 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: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ I-Tauk 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 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 0 Dispenser Containment Sensor(s). Model: ULS ® Dispenser Containment Sensor(s). Model: ULS ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Cham(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ® Dispenser containment Sensor(s). Model: ULS ® Dispenser containment Sensor(s). Model: ULS ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floai(s) and Chain(s)_ ❑ Dispenser Containment Float(s) and Cham(s)- Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Vah*s). ❑ Dispenser Containment Float(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 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 aPlot 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): JOSE OCHOA Signature: , Certification No.: B35931 License Testing Company Name: FRANZEN-HIL.L Phone No.: (559) 688-2977 Testing Company Address: 1100 N J ST TULARE CA 93274 Date of Testing/Servicing: 1127/2016