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J u 1.30. 2015 6:53A 1 11110N#2RING 'FI 'I' �. 051 � P. 2 U.rE RY All Jurisdiction$ Within the State of Cali ea Author4y 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 equipmem. -rr.^ �°^ • - , H® We; separate certification or report must be nrenared for each monitoring evatem control Hanelbythetechniei a or.A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this forst tot o regulating UST systems within 30 days of test date.lRatfuet#a JUL 3 0 2015 A. General Information ;.�: I Facility Name: H & M KIWK SERV BW98 Site Address: 2501 E JACKSON City: ESCALON CA Zip: 86320 Facility Contact Person: ALEX Contact Phone No.: ri209) 838-3$71 Make/Model of Monitoring System: GILSARGO TLS -350 Dake of Testing/Seevicing: 7128!2096 B. Inventory of Equipment Tested/Certified seek the approgriate boxes to indicate s ecttic equipment ins ected/servicedo: Tank 1D: 87 Tank ID: 91 ® In -Tank Gauging Probc. Model: VEEDER ROOT ® In -Tank Gauging Probe, Model: VEEDER ROOT ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 -� ® 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 Line Leak Detector. Model: V-M.I ❑ Electronic Line Look Detector, Modal; ❑ Electronic Line Leak Detector. Model: IDTank Overfill / High -Level Sensor. Model: FLAPPER ® Tank Overfill / High -Level Sensor. _ Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DIESEL TankID: 0 In -Tank Gauging Probe, Model: VEEDER ROOT I] In -Tank Gauging Probe. Model 0 Annular Space or Vault Sensor. Model: 420 _ ❑ Annular Space or Vault Sensor. Model: Piping Sump t Trench Sensor(s), Model: 208 ij Piping Sump /Trench Sensogs). Model; [] fill Sump Sensor(s). Model: _ ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: RED_ JACKET 1 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic tine Leak Detector. Model: ❑ Electronic Line Leak Detector. Model; ® Tank Overfill /High -Level Sensor. Model: FLAPPER ❑ 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: 112 Dispenser ID: 3/4 (� Dispenser Containment Sensor(s). Model: FLOATS ❑ Dispenser Containment Sensor(a). Model: FLOATS r Shear Valve(s). ® Shear Valve(s). Dispenser Containment iFloot(s) and Chain(s). ED Dispenser Containment fioat(s) and Chain(s) Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Senso0s). Model: ❑ Shear valve(s). ❑ Shear valve(s). 0 Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser IID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Semor(s). Model; ❑ Shear Valve(s). ❑ Shear valve($). 9 Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Choin(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 &IA -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 aet-up Alarm.,fiistary _ rt Technician Name (print): GARY HARRIS Signature: Certification No.;, B340501 License, No.: Testing Company Name: L.C.SERVICES Phone No.: (558) -1730 Testing Company Address: 3887 N VALENTINE FRESNO CA 93722 Date of Testing/Servicing; 7129/2016 UN -036 -1/6 www.unidocs org Rev. 01/17=