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0 0 MONITORING SYSTEM CERTIFICATION P or (,'se By All Jurisdictions Within the State qfCaliforflia Awhorfty- Cited: Chapter 6.7. Heafth and Safety' Code, Chapter 16. Division 3. Litle 23. Cah forma Cotle ref 14,911/c/11011 -V This forin must be used to document testing and servicing of monitoring equipment. A separate certification orxcPqq_must _hiLpreA!4_tcd f(IT -each monitr Jog astem control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator, 'I he owner/tit trator must submit a copy ofthis form to the local agency regulating I.JS'I'systems within 30 days oftest date. A. General Information Facility Name: GEORGE KISHIDA TRUCKING County: SAN JOAqUIN Site Address: 1725 ACKERMAN DR — City: LODI Facility Contact Person: KELLI contact Phone 209-368-0603 Make/Model of Monitoring System: OMNTEC Date ofTesting/Servicing: 116/20114 Check the appropriate boxes to indicate specific equipment inspecteu/serviceo: 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 !rift' that this information is correct and a Plan showing the layout of monitoring equipment. For any equipment capable of gener, ting such reports, I have also attached a copy of the report; (check all that app/r): 0 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 Monitoring Certification Test Report DEC 07 20115 1 of4 Tank ID: T5 - DSL Tank ID: T6 - DSL 0 In -Tank Gauging Probe. Model Al AG [0 In -Tank Gauging Probe. Model: NIAG Annular Space or vault Sensor. Model: OPTIC El Annular Space or Vault Sensor. Model: Piping Sump I Trench Sensor(s). Model: FLOAT' SWITCH 0 Piping Sump /Trench Sensor(s). Model: FLOAT SWI'.].'(*I I n Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ED Mechanical Line Leak Detector. Model: FXIDN' ED Mechanical Line Leak Detector- Model: FXIDN' n Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: FLAPPER 0 Tank Overfill / I ligh-Level Sensor. Model: FLAPPER rl other (specify equipment type and niodet in Section 1: on Page 2). 0 Other (specify equipment type and model in Section I on Page 2 Tank ID: Tank ID: El In -Tank Gauging Probe. Model: [I In -Tank Gauging Probe. ModcL n Annular Space or Vault Sensor. Model: 171 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: 0 Mechanical Line Leak Detector. Model: D Mechanical Linc Leak Dtlector, Model: D Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector- Model: 0 'tank Overfill / High -Level Sensor. Model: 0Tank Overfill / High -Level Sensor. Model: [I Other (specify equipment type and model in Section 1: on Page 2). 0 Other (specify equipment type pe and model in Section E on Page 2 Dispenser ID: I Dispenser ID: I SAT [] Dispenser Containment Sensor(s), Model: El Dispenser Containment Sensor(s). Model: ED Shear Valve(s). Shear Valve(s). ED Dispenser Containment Floatts) and Chain(s). Dispenser Containment Float(s) and Chain(s,), Dispenser ID: 2 Dispenser ID: [I Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: 10 Shear Valve(s), El Shear Valve(s). 0 Dispenser Containment Floats) and Chain(s). [I Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: n Shear Valve(s). [] Shear Valve(s). El Dispenser Containment Floatts) and Chain(s). n Dispenser Containtrient Float(s) and Chain(0. Check the appropriate boxes to indicate specific equipment inspecteu/serviceo: 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 !rift' that this information is correct and a Plan showing the layout of monitoring equipment. For any equipment capable of gener, ting such reports, I have also attached a copy of the report; (check all that app/r): 0 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 Monitoring Certification Test Report DEC 07 20115 1 of4