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Mar, 21, 2016 9: 33AM No. 2450 P, 2 NIT NG SYSTEMTIFIC For e By All Jurisdictions Within the State of California ,Authority Cited: Chapter 6.7, Kealth and Safety Code; Chapter 16, Division 3, Title 23, Calif _ of ir. L This form must be used to document testing end servicing of monitoring equipment. A settlate certification or report must be Qrepared for each monitoring system cpnggl pmel by the technician who performs the work. A copy of this form must be provided to the otyyU� operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test dWII A. General Information ENVIRONMENTAL Facility Name: H&M IK SERVE g ti �� R,AC N 1 Site Address: 2801 E. JACKSON City: ESCALON, CA Zip: 95320 Facility Contact HASSAN Contact Phone No.: (209) 838-3971 Make/Model of Monitoring VEEDER ROOT TLS -350 B. Inventory of Equipment Tested/Certified Check the annronrlate boxes to indieste sneciCte eauinment insoccted/serviced! Date of Testing/Servicing: 3117/2016 Tank 10: 87 _ Tank ID: 91 ® In -Tank Gauging Probe. Model: veeder root ® In -Tank Gauging Probe. Model: veeder root _ iZ Annular Space or Vault Sensor. Model: 420 ® Annular Spnoe or Vault Sensor. Model: 420 0 Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s), Model: 208 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: _ ® Mechanical Line Leak Detector. Model: RED JACKET ® Mechanical Linc Leak Detector. Model: RED JACKET ❑ Electronic tine Leek Detector. Model; ® Electronic Line beak Detector. Model: IN Tank Overkill / High -Level Sensor, Model: FLAPPER Tank Overfill 1 High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment type and model in Scclion F on Page 2). © Other (specify equipment type and model in Station L, on Page 2). Tank ID: DSL Tank ID; 0 In -Tank Gauging probe. Model: veeder root 0 In -Tarek Gauging Probe. Model: ® Annular Space or vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Scltsor(s), Model: 20$ M Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Senwo s). Model: ❑ Fill Sump Sensor(s) Model: ® Mechanical kine Leak Detector. Model; RED JACKET ❑ Mechanical Line Leak Deteeloe. Model: Q (electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model; FLAPPER ®'rank Overfill / High -Level Sensor. Model: 0 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: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). Dispenser Containment Floats) and Chain(s). M Dispenser Containment Float(s) and Chain(s). Dispenser ID: 314 Dispenser ID: El Dispenser Containment Sensor(s), Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ® Dispenser Containment I'loat(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s), Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ®Dispenser Containment Sensor(s). Model: �) Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Floats) and Chain(s). ❑ 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' g'tidelines. ,Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment.For any agar ment capable of generating such reports, I have also attached a copy of the report; (check all Mat apply): El set-up ( A,larm history report Technician Name GABRIEL VENEGAS Signature: . 8 Certification No.: B40893 License. No.: Testing Company Testing Company Phone No.: (559) 444-1730 3887 N VALENTINE FRESNO CA 93722 pate of Testing/Servicing: 3/1712016 Page 1 of 3 Rev (2/08)