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MONIT"wNG SYSTEM CERTIFICA&ION For Us All Jurisdictions Within the State of Californ 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. If tt t" i Panel c : "t„ ri.,a at #ie &eil a 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. r "'^ eti its afe a a en the baek-efthisjmge. RECEIVED A. General Information Facility Name: ESCALON MINI MART Site Address: 1097 E. YOSEMITE Facility Contact Person: SILL Make/Model of Monitoring System: AUTOSTICK JR4 B. Inventory of Equipment Tested/Certifled _ __ a ..a.. ..;..e..a.-add/--wined_. i(; a 201-7 Bldg. No.: City: ESCALON Zi : 95320 Contact Phone No.: 20 - 1_. EALTH Date of Testing/Servic._ _ 2� ,d \,Reel& ane n ru rla/e r✓V3es so --a.c o c Tank ID: 91 ® In -Tank Gauging Probe. Model: AUTO STICK Tank ID: 87 ® 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 0 Mechanical Line Leak Detector. Model: RED -JACKET ❑ 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: _.. _ ❑ 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: Q Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: n Electronic Line Leak Detector. Model: ___.___.__..._.__ ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: M Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and "model in Section E on Page 2). E] Other (specify equipment type and model in Section E on Page Dispenser ID: 1-2 Dispenser ID: 3-4 N 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 Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 N Dispenser Containment Sensor(s). Model: ULS 0 Dispenser Containment Sensor(s), Model: ULS 19 Shear Valve(s). 0 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 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 tor every tank and dispenser at tile laCHITY. 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 a Site -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): JOSE OCHOA Signature: a Certification No.: 835931 License Testing Company Name: FRANZEN-HILL Phone No.: (559) 688-2977 Testing Company Address: 1100 N J ST TULARE CA 93274 Date of Testing/Servicing: 1/11/2016