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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Stale of California 4zahoray Cited: Chapter 6.7. Health and Sqfetv Code: Chapter 16. Division 3. Title 23. California code of This form must be used to document testing and servicing of monitoring equipment. A separate certification ffreport AMgt _ K g�d_L in 12repared for each 010171 1� ' ' system control panel by the technician who performs the work. A cop), of this form must be provided to the tank system owner/operator. Theownerlol,crator must submit a copy or this form to the local agency regulating LIST systems within 30 days of test date. A. General Information Facility Name: GEORGE KISHIDA TRUCKING County: SAN JOAQUIN Site Address: 1725 ACKERMAN DR City: LODI -Contact Phone 209-368-0603 Facility Contact Person: KELLI Date ofTesting/Servicing: Make/Model of Monitoring System: OMNTEC B. Inventory of Equipment Tested/Certified Tank ID: T5 - DSL [D In -*rank Gauging, Probe. Model: MAG 10 Annular Space or Vault Sensor. Model: OPTIC: Piping Sump / Trellell Sensor(s). Model: FLOAT SWITCH ❑ Fill Sullip Sensor(s). Model: Mechanical Line Leak [)elector. Model: FXIDN' ❑ Electronic Line Leak Delector. Model: Tank Overfill / I ligh-Level Sensor. Model: FLAPPER Other (specify equipment type and model in Section E on Page 2). Tank ID: n In -Tank Gauging probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump /"I'tench Sensor(s). Model: Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector, Model: r_1 Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: n Other (specify equipment type and model in Section F on page 2), Model: FLAPPER 0 Other (specify equipment type and model in Station I., on Page 2 Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). Model: Tank ID: T6 - DSL 0 in -Tank Gauging Probe. Model: NIAG E] Annular Space or Vault Senior. Model: 0 Piping Sump / Trench Sensor(s). Model: FLOAT SWITC11 0 Fill Sump Sensor(s). model: 0 Mechanical Line Leak Detector, Model: FXIDV [:1 Electronic Line Leak Detector. Model: 10 Tank Overfill Y i-jigh-Level Sensor. Model: FLAPPER 0 Other (specify equipment type and model in Station I., on Page 2 Tank ID: [3 In -Tank Gauging Probe. Model: [] Annular Space or Vault Sensor, Model: 0 piping Sump / Treneh Sensor(s). Model: n Fill Sump Sensor(s). Model; [] Mechanical Line Leak Detector. Model: f-1 Electronic Line Leak Detector. Model: ❑ Tank Overfill / Fligh-Level Sensor, Model: ❑ Other (specify equipment type and model in Section F. on Page 2 . Dispenser ID: I SAT 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). I'M ni—n— Containment Float(s) and Chain(,;). N Dispenser Containment Fioaus) anu,, niuuks). Dispenser ID: 2 Dispenser ID: C] Dispenser Containment Sensor(s). Model: [] Dispenser Containment Sensor(s). Model: Shear Valve(s). Dispenser Containment Float(s) and Chain(s). E] Shear Valve(s). [I Dispenser Containment Float(s) and Chain(s). Dispenser ID: A Dispenser ID: crContainmentSensor(s), Model: El Dispens .4 : 0 Dispenser Containment Scrisor(s). Model: , b V , (s Shear Valve(s) . , t==� ispenser Containin:ent:Floatts) and Chain(s). Dispenser 0 Shear Valve(s). A and Chauns). Dispenser Containment Floans Check the appropriate boxes to indicate specific equipment inspected/serviced, 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 v !rify that this Information is correct and a Plan showing the layout of monitoring equipment. For any equipment capable of genert ting such reports, I have also attached a copy of the report; (check all that apply): (@ System set-up 0 Alarm history report Technician Name (print): RHOME DESBIENS Signature: - Certification 112111 RD License No.: 433159 Testing Company Name: B. Z. Service Station Maintenance Phone No.: (916) 371-2380 Site 1041 Triangle Court West Sacramento, CA 95605 Date of Testing/Servicing: 11/20/2015 CLIV Monitoring Certification Test Report DEC 2 4 203 1 of -WO