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MONODRING SYSTEM CERTIF*ATION 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. if mere than enem-n-i—ing sys—i-0ontrill rime!: :11—lat ei+ity A urate certification or report must be prepared for each monitorine 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. jn,S*i..;__ oil the bilLk of this rag" 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 the steerveriate boxes to indicate sgSS!L1c ,jeuiement inseected/serviced-: Tank ID: 87 Tank ID: 91 0 In-Tank Gauging Probe. Model: VEEDER ROOT ❑In-Tank Gauging Probe. Model: VEEDER ROOT Annular Space or Vault Sensor. Model: 420 Annular Space or Vault Sensor. Model: 420/SPLIT Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: rl Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: RED JACKET 0 Mechanical Line Leak Detector. Model: REQ JACKET ❑Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor, Model: VEEDER ROOT Z Tank Overfill/High-Level Sensor. Model: VEEDER ROOT F-1 Other(specify equipment type and model in Section E on Page 2). El 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 0 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 420 [1 Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 208 Fl Piping Sump I Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: []Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: RED JACKET 0 Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: 0 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). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 3/4 El Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: E3 Shear Valve(s). Z Shear Valve(s). 10 Dispenser Containment Float(s)and Chain(s). ID Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: [I Dispenser Containment Sensor(s). Model: 1771 Shear Valve(s). 171 Shear Valve(s). El 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: n Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). El Shear Valve(s). El Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or 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 a Sk-e-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 all that apply): System set-up Alarm history report Technician Name(print): PETER WESTBROOK Signature: Certification No.: B46675 License. No Testing Company Name: L.C.SERVICES Phone No.:(559) 444-1730 Testing Company Address: 3887 N VALENTINE FRESNO CA 93722 Date of Testing/Servicing: 8/30/2017 UN-036-1/6 www.unidoes.org Rev.01/17/08