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MON]WRING SYSTEM CERTIFOATION 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 of Regulations This form must be used to document testing and servicing of monitoring equipment. +A separate certification or report must be prepared far each monitoring 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. 1H.-ItFue-i-efis L -k of this page. A. General Information Facility Name: H &M KWIK SERVE B 9 Bldg.No.: Site Address: 2501 E.JACKSON City: MODESTO Zip: 95320 Facility Contact Person: MIKE Contact Phone No.: (209) 838-3971 Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 8/30/2017 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecific!Sulpment inspected/servic-- Tank ID: 87 Tank ID: 91 0 In-Tank Gauging Probe. Model: VEEDER ROOT [I In-Tank Gauging Probe. Model: VEEDER ROOT Annular Space or Vault Sensor. Model: 420 ED Annular Space or Vault Sensor. Model: 420/SPLIT Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: 208 0 Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ED Mechanical Line Leak Detector. Model: RED JACKET Mechanical Line Leak Detector. Model: RED JACKET C]Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor, Model: VEEDER ROOT Tank Overfill 11 High-Level Sensor. Model: VEEDER ROOT ❑Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Tank ID: DIESEL Tank ID: 0 In-Tank Gauging Probe. Model: VEEDER ROOT El In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 420 El Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensoi(s). Model: 208 Fl Piping Sump/Trench Sensor(s). Model: F-1 Fill Sump Sensor(s). Model: [I Fill Sump Sensoqs). 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: Tank Overfill/High-Level Sensor. Model: VEEDER ROOT ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). C1 Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 314 []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: El Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: El Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). E]Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). - - ii- *If the facility contains more tanks or dispensers,copy this form. Include information n-nation 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 a 84e-Plot 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 aft that apply): System set-up Z Alarm history report Technician Name(print): PETER WESTBROOK Signature: Certification No.: B46676 License. No Testing Company Name: L.C.SERVICES Phone No.: 30 Testing Company Address: 3887 N VALENTINE FRESNO CA 93722 Date of Testing/Servicing: 8/30/2017 UN-036-1/6 www.unidocs.org Rev.01/17/08