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r 1 0 0 MONITORING SYSTEM CERTIFICATIONRECEIVED 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, Cali%rnia Code o/Regulations NOV 2 5 2013 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoriny 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. ENVIRONMENTALWALTH A. General Information PERMMSEFMCES 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 of Testing/Servicing: 11/7/2013 B. Inventory of EaUiDment Tested/Certified Tank ID: T5 - DSL Tank ID: T6 - DSL ® In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: OPTIC ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: FLOAT SWITCH ® Piping Sump / Trench Sensor(s). Model: FLOAT SWITCH ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: FXIDV ® Mechanical Line Leak Detector. Mudd: FXIDV ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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 ❑ 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: I Dispenser ID: I SAT ❑ 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: 2 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). _ ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). •— app,up..aac uua eu 11u1caie spccuic equipment mspeeteatservtcea: 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 Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (clteck all that apply): El System set-up ® Alarm history report Technician Name (print): RHOME DESBIENS Signature: Certification 112111RD 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: 11/7/2013 Monitoring Certification Test Report 1 of 4