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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, California Code qfRegujjAN 0 4 2018 This form must be used to document testing and servicing ofnionitoring equipment. A separate certification or report must be or IMENDLIUMTH system control panel by the technician who performs the work. A copy of this form must be provided to the tank system ownedopFaW 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: Geroge Kishida Inc County: San Joaquin Site Address: 1725 Ackerman Dr Citv: Lodi Facility Contact Person: Contact Phone 209-368-0603 Make/Model of Monitoring System: Omnitec Date of Testing/Servicing: 11/17/2017 B. Inventory of Equipment Tested/Certified Tank ID: DSL -1 0 In -Tank Gauging Probe. Model: mag [D Annular Space or Vault Sensor. Model: optic Z Piping Sump / Trench Sensor(s), Model: optic E] Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector, Model: FX1DV M Electronic Line Leak Detector. Model: E] Tank Overfill / High-Levc1 Sensor, Model: [I Other (specify equipment type and model in Section E on Page 2). i 'EMT , r#3 0 1 '_� 0 in -'rank Gauging Probe, Model: mag ❑ Annular Space or Vault Sensor. Model, split Piping Sump / Trench Sensor(s), Model: optic ❑ Fill Sump Sensor(s), Model: Mechanical Line Leak Detector. Model: FXIDV ❑ Electronic Line Leak Detector. Model: 0 'Tank Overfill / High -Level Sensor. Model: El Other (specify equipment type and model in Section E on Page 2), Tank ID: Tank ID: 0 In -Tank Gauging Probe, Model ❑ In -Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model• ❑ Annular Space or Vault Sensor. Model: ED Piping Sump /Trench Sensor(s). Model: 0 Piping Sump 'Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector, Model: 171 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector- Model: C] Tank Overfill / High -Level Sensor. Model: [] *Tank Overt -ill / High -Level Sensor. Model: [I Other (specify equipment type and model in Section E on Page 2). [1 Other (specify equipment type and model in Section E on Page 2). Dispenser ID:_ i Dispenser ID: 2 F1 Dispenser Containment Sensor(s) Model: El Dispenser Containment Sensor(s). Model: Shear Valve(s). Z Shear Valve(s). Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). Dispenser ID: SAT Dispenser ID: E3 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 ID: 0 Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: I 0 Shear Valve(s). ❑ Shear Valve(s). E] Dispenser Containment Float(s) and Chain(s). Containment Float(s) and Chain(s). eck the appropriate boxes to indicate speciric 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 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; (check all that apply): M System set-up 0 Alarm history report Technician Name (print): Certification A22883 Testing Company Name: Rhorne Desbiensq Signature: License No.: 433159 B. Z. Service Station Maintenance Phone No.: (916) 371-2380 Site 1041 Triangle Court West Sacramento, CA 95605 Date of Testing/Servicing: 11/17/2017 Monitoring Certification Test Report 1 of 4