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x . MONITORING SYSTEM- CERTIFICATION 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. -it etlot> a-ejie-tau ' is l'tteilit3, *A serrate certification or report must be prepared for cacti monitoring system contra! panel by the technician who performs the work, 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 data.—in ;t+uoiic ervsrinsv en ike gym,; �, .!;i .i,:,, A. General Information Facility Name: H & M KIWK SERV BW98 Bldg. No.: Site Address: 2501 E JACKSON City: ESCALON CA Zip: 95320 Facility Contact Person: ALEX Contact Phone No.: (L091 838-3971 Make/Model of Monitoring System: t3ILBARCO TLS -360 Date of Testing/Servicing: 7/29120/6 B. Inventoiy of L, quipmlent Tested/Certified t.:necat the appropriate boxes to lndieate specific egatipmeut ins eeted/servii Tank ID: 87 19 In -Tank Gauging Probe. Mord: VEEDER ROOT 0 Annular Space or Vault Sensor. Model: 420 ® Piping Sump ITrench ScnsoKs). Model: 208 Fill Sump Sensor($). Model: Mechanical Line Leak Detector. Model: RED JACKET ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / I ligh-Level Sensor. Model: FLAPPER i] Other (specify equipment type and model. in Section I: on Page 2). TanklD: DIESEL C] Other (specify equipment type and model in Seafion E on 19 in -Tank Ganging Probe. Model: VEEDER ROOT Annular Space or Vault Sensor. Model: 420 - y Piping Sump / Trench Sensor(s). Model: 206 Sump Smor(s). Model: Mechanical Line Leak Detector. Model: REI? JACKET Electronic Line Leak Detector. Model: ® Tank Overfill / Hleb-Level Sensor. Model: FLAPPER ❑ Other (specify equipment type -and model in Section E on Page 2). Dispenser ID: 112 - © Dispenser Containment Sensor(s). 0 Shear Valve(s). ® Dispenser Containment floa(s) and Model. FLOATS Dispenser ID: a Dispenser ContainmentSensor(s). Model: Q Shear Valve(s), o Dispenser Containment 0oat(s) and Chainf7 Dispenser ID: _ r0 DispwserContainment Sensor(s). Model: [--r_ Shear Valve(s). 0 Dispenser Containment Roat(s) and Chain(s). facility contains more tanks or dispensers, copy Tank ID: 91 19 in -Tank Gauging -Probe, Model. VEEDER ROOT 21 Annular Space or Vault Sensor. Model: 420 ® Piping Sump /Trench Sensor(s). Model 208 [j Fill Surtgr Sensor(s). Modci: ® Mechanical kine Leak Detector. _ Model. V.IH.I G Electronic Line Leak Detector. Model: N Tank Overfill / High -Level Sensor. Model: FLAPPER © Other (specify equipment type and model in Section E on Page 2). Tank ID: Li L- 0 In -Tank Gauging Probe. Model: F1 Annular Spioe or Vault Sensor. Model: El Piping Sump / Trench Sensor(a). Model: © Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: © Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: C] Other (specify equipment type and model in Seafion E on Dispenser 1W. 314 ❑ Dispenser Containment Sensor(s). Model: FLOATS ® Shear Valve(s). ® Dispenser Containment Floats) and Chain(s). Dispenser ID: ❑ Dispenser Coataibment Swwr(sj Model: El Shear Valve(s). ❑ Dispenser Containment Ploat(s) and Chain(s), 1 Dispenser ID: [� Dispenser Containment Sensor(s). Model: - ❑ Shear Valve(s). E] DispenwContainment Float(s) and Chain(s). information for every tank and dispenser at the 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. manufaeturors' checklists) necessary to verify that this information is correct and a Silo -t' at Pian showing the layout of monitoring equipment. For any egtd ment capable ofgener ting such reports, I bave also attached a copy of the report; (check all that apply): System set-up Alarm istory �rt Technician Name (print): GAMY HARRIS Signature: ldsa(Ion No.; B340501 Liter , -sting Company Name: L.C.SERVICES Phone No.: 659) 444-1730 Testing Company Address: 3087 N VALENTINE FRESNO CA 03722 Date of Testing/Servicing: 712912016 UN -036-1/6 www.unidees.org Rev. 01/17108