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MONITOUNG SYSTEM CERTIFIORTION For Use By All Jurisdictions Within the State 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 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. A. General Information Facility Name: Quick Stop Market #76 Site Address: 1030 S. Olive Ave. Facility Contact Person: Michael Karyelot Make/Model of Monitoring System: Gilbarco EMC B. Inventory of Equipment Tested/Certified Check the aDDronriatc boxes to indicatespecific equipment inspected/serviced: City: Stockton Bldg. No.: Zip: 95215 Contact Phone No.: 510 657-8500 Date of Testing/Servicing: 08 /19 /2005 Tank ID: Gasoline - 87 Tank ID: Gasoline - 91 ■ In -Tank Gauging Probe. Model: 0847390-109 N In -Tank Gauging Probe. Model: 0847390-109 ■ Annular Space or Vault Sensor. Model: 734380-303 0 Annular Space or Vault Sensor. Model: 734380-303 Piping Sump / Trench Sensor(s). Model: 734380-208 0 Piping Sump / Trench Sensor(s). Model: 734380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ■ Mechanical Line Leak Detector. Model: FE PETRO STP -MLD ■ Mechanical Line Leak Detector. Model: FE PETRO STP -MLD ❑ 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 a and model in Section E on Pae 2). 1 ❑ Other(specify equipment a and model in Section E on Pae 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: ❑ 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 a ui ment e and model in Section E on Pae 2). ❑ Other (specifX equipment t e and model in Section E on Pae 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ■ Shear Valve(s). E Shear Valve(s). E Dispenser Containment Floats and Chain(s). 0 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). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s). 1 ❑ 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 a Plot Plan showing the layout of monitoring equipment. For any equipment capable of rating such r orts, I have also attached a copy of the report; (check all that apply): ®System set-up ® rm history rt Technician Name (print): Bruce Stewart Signature: Certification No.: 006-05-0810 License. No.: 617238 Testing Company Name: Walton Engineering, Inc. Phone No j 916 ) 373-1152 Site Address: 3900 Commerce Drive, West Sacramento, CA 95691 Date of Testing/Servicing: 08 / 19 / 2005 UN -036 - 1/4 CUPA: San Joaquin County Env. Health INSPECTOR: John Jackson Page I of 3 WALTON�. ENGINEERING, INC, www.unidoes.org Rev. 06/04/01