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MONITO&G SYSTEM CETIIC 4N 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 stearate certification or report must be prepared for each Monitoring system control panel by the technician who performs the work. A copy of this form must be provide C:ern /operator. - The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days A. General Information Facility Name. H&M KWIK SERVE Site Address: 2501 E. JACKSON Facility Contact HASSAN Make/Model of Monitoring VEEDER ROOT TLS -350 B. Inventory of Equipment Tested/Certified Cheek the arwronriate boxes to indicate cnPrirr anntmm�nr.ne. n ro ri.e ..: -a BIdg. l�o 'R �Q� City: ESCALON, CA Zip: 95320 Contact Phone No.: (2 ALT Date of Testing/Servic ID: 87 Tank ID: 91 'Tank Gauging Probe. Model: veeder root N In -Tank Gauging Probe. Model: veeder root nular Space or Vault Sensor. Model; 420 F ® Annular Space or Vault Sensor. Model: 420 ing Sump /Trench Sensor(s). Modci: 208 ®Piping Sump/ Trench Sensor(s). Model; 208 l Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: N Mechanical Line Leak Detector. Model: RED JACKET N Mechanical Line Leak Detector. Model: RED JACKET ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector_ Model: N Tank Overfill / High -Level Sensor. Model: FLAPPER N Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). y equipment type and model in Section E on Page 2). Tank ID: DSL N In -Tank Ganging Probe. Model: veeder root r�nkD ing Probe. Model: N Annular Space or Vault Sensor. Model: 420 e or Vault Sensor. Model: N Piping Sump / Trench Sensor(s). Model: 208 pngump/ Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: RED JACKET ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: N Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section Eon Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 112 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). N Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ®Dispenser Containment FIoat(s) and Chains). Dispenser ID: 314 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). N Dispenser Containment Float(s) and Chains). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: N Shear Valve(s). ❑ Shear Valves). N Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). orf th f '1' t t ' e act t y con ams 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 Plot Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (cheek all that apply): ❑ System set-up ❑ Alarm history report Technician Name GABRIEL VENEGAS Signature: Certification No.: B40893 License. No.: Testing Company Testing Company L.0 SERVICES 3887 N VALENTINE FRESNO CA 93722 Page 1 of 3 Phone No.: (559) 444-1730 Date of Testing/Servicing: 3117/2016 Rev (2/08)