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MONITORING SYSTEM CERTIFICATION For Use By A It Jurisdictions Within the State ofCaWornia 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.,1 gmepe th"efle fft@fA04Rj'b'Sys—ea IF81 palwl if, 4*4- a-A.-AMAM Oertiflcatign ,�egort must be pMagg-for each monitorinp,system control pMI by the technician who performs the work. A copy of this orm must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency f regulating UST systems within 30 days of test date, insiou gjangme lig-, Page, A. General Information Facility Name: H&M KMK SERV Bldg.No.: Site Address: 2501 E.JACKSON City: ESCALON Zip: 96320 Facility Contact Person: HASSAN Contact Phone No., (209) 838-3971 Make/Model of Monitoring System: TLS-360 Date of Testing/Servicing: 713112012 B. Inventory of Eq UiPment Tested/Certified Check the a2gorlate boxes to indicates IQs equipment ins pected/servicedi- Tank ID: 87 Tank ID: 91 0 In Tank Qw4ag Probe, Model; VEEDER-ROOT 0 In-Tank Gauging Probe. Model: VEEDER-ROOT 12 Annular Space or Vault Sensor, Model: 420 0 Annular Space or Vault Sensor. Model; 420 Piping Sump/Trench Sensor(s), Model! 208 1Z Piping Sump I Trooh Scrisor(s). Model, 208 [3 Fill Sump Scasor(s). Model, 0 Fill Sump Sensorr(s), Model: 0 Mechanical Line Leak Detector. Model; RED-JACKET 0 Mechanical Line Leak Detector, Model: VMI 0 Electronic Line Leak Detector, Model: n Electronic Line Leak Detector. Mo*]; [I Tank Overfill/High-Level Samr, Model- C1 Tank Overfill/High-Level Sensor, Model., 0 Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section 16 on Page 2), Tank ib: DIESEL Took ID; 1@ In-Tank Gauging Probe. Model! VEEDER-ROOT El In-Tank Gauging Probe, Model: 0 Annular Space or Vault Sensor. Model. 420 E3 Annular Space or Vault Sensor, Model: 0 Piping Sump I Trench Sensor(s). Model; 208 El Piping Sump/Trench Sensor(s). Model: Cl Fill Sump Sensor(s). Model: 171 Fill Sump Sensor(s), Model, 0 Mechanical Line Leak Detector, Model: RED-JACKET ❑Mechanical Line Leak Detector. Model, El Electronic Line Leak Detector. Model, Electronic Line Leak Detector. Model; [I Tank Overfill/High-Level Sensor. Model; Tank Overfill/High-Level Sensor. Model; El Other(specify equipment type and model in Section E on Page 2). 13 Other(specify equipment type and model in Section E on Page 2). Dispenser 1D.- 11-2 Dispenser ID: 3-4 0 Disposer Containment Sonsor(s). Model: ❑Dispenser Containment Sensor(s). Model! [9 Shear Valve(s). Shaw Valve(s). E5 Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser 10; Dispenser ID: 11 Dispenser Containment Sensor(s), Model: (:1 Dispenser Containment Sensor(s), Model: 0 Shear Valve(s), Shear Valve(s). Dispenser L P 0 Shear 03 Dispenser Containment Float(s)and Chain(s), E3 Dispenser Containment Float(s)and Chain(s), ob ......... Dispenser ID: Dispenser ID: C3 is C3 Dispenser Containment Sensor(s), Model; 0 Dispenser Containment Sensor(s). Model; 0 Shear Valve(s), 171 Shear Valve(O. Shear Fopcnscr Containment Float(s)and Chain(&). j C3 Dispenser Containment Float(s)and Chain(s). *If the theility contains more tanks of 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 afiltemP_Iot 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 aff that apply): System set-up Alarm history report Technician Name(print); JOSE OCHOA Signature; ./C=1ffl11ftUQL_N_0, B35931 Testing Company Name: LC SERVICES Phone No.:�559 -�173O Testing Company Address: 3.887 No VALENTINE Date of Testing/Servicing:7/3112012 UN-036-116 www.ouidomorg Rev-01/17M