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MONI*RING SYSTEM CET IFl TION <br />For Use By All Jurisdictions Withitf the State of Cali is <br />Authority Cited:- Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code of Regulations <br />This form must be used to document tooting and servicing of monitoringequipment If ffiefe thaii ON <br />� m <br />*6 fiwiktyrte certification or reDc, Ddn&jystern control �el by the technician who perform the work a - <br />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 <br />regulating UST systems within 30 days of test date, lwom fis-We 4ws-foge- <br />A. General Information <br />Facility Name- H & M KWIK SERV BW98 <br />Bldg. No., <br />Site Address: 2501 E. JACKSON <br />City: ESCALON — Zip: 9_6320 <br />— <br />Facility Contact Person: MIKE HASSAN <br />Contact Phone trio.: (209) 838-3971 <br />Make/Model of Monitoring System: TLS -350 <br />W&D"Vicing: 8/8/2014 <br />B. Inventory of )Equipment Tested/Certified <br />Check the appropriate boxes to indicate sjxviflc Ssuipment iRsPectW5CrVicedA.L___ A 17 91 ju.� <br />Tank ID; 87 <br />Tank ID! 91 <br />0 in -Tank Gauging Probe. Model: VIR <br />ftyt Mq AL Hq <br />go VM 420 <br />Eg Annular space or vault Sensor. Model; VIR 420 <br />Mr, T model: 208 <br />T <br />19 Piping Sump J Trench Sensor(s): Model., VIR 208 <br />11 Fill Sump sensor(s). Model: NIA <br />Pipi Su NIR <br />0 Piping <br />171 Fill Sump Sensor(s). Model; NIA E <br />M Mechanical Line Leak Detector. Model'. RED JACKET <br />0 Mechanical Line Leak Detector. Model! VMI <br />D Electronic Line Usk Detector. Model: WA <br />Electronic Line, Leak Detector. Model: WA <br />0 Tank Overkill / High -Level sensor. Model: FI-APPER <br />2). <br />Tank Overfill / HO -Level Sensor. Model: FLAPPER <br />0 Other (specify equipment type and model in Section E on Page 2). <br />❑ Other (specify equipment type and model in Section E on Page <br />Tank ED: DSL <br />Tank ID, <br />0 In -Tank Gauging prof. Model: VIR <br />[j In -Tank Gauging Probe- Model: <br />0 Annular Space or vault Sensor. Model; VIR 420 <br />❑Annular Space or Vault Sensor. Model; <br />ED Piping Sump /Trench Sensor(s). Model,- VIR 208 <br />— <br />Piping Sump / Trench Sensor($). Model-, <br />Fill Sump Sensor(s). Model: NIA <br />rl Fill Sump Sensor(s)- Model: <br />Mechanical Line Leak Detector. Model: RED JACKET <br />E] Mechanical Line Look Detector, Model: <br />F-1 Electronic Line Leak Detector- Model; NIA <br />0 Electronic Line Leak Detector- Model; <br />10 Tank Overfill I High -Level Sensor. model: FLAPPER <br />Other (specify equipment type and model in Section 2 on Page 2). <br />Q Tank Overfill I High -Lend Sensor. Model: <br />0 Other (specify eqUiPman " and model in Section E on Page 2)_ <br />Dispenser ID: 112 <br />Dispenser JD' 314 <br />0 Dispenser Containment SOXRSO*)� Model: WA <br />[] Dispenser Containment Sensor(s). Model: NIA <br />1@ Shear Valvo(s). <br />0 Dispenser Containment Float(s) and CWn(s). <br />Shear valve(s). <br />Ehspmw Containment Float(s) and Chain(s). <br />Dispenser JID, <br />[3 Dispenser Containment Sensor(s). Model: <br />Dispenser ID' <br />El Dispenser Containment Sensor($)- Model, <br />[I Shear Valve(s). <br />[] Shear Valve(s). - <br />n Dispenser Containment MORO) and Chain(s), <br />0 Dispenser Containment F1005) and Chain(s). <br />Dispenser ID: <br />0 Dispenser Containment Sensor(s). Model: <br />Dispenser UD-' <br />4; <br />0 Dispenser Containment Sensor(s). MOM: <br />0 Shear ValveW. <br />d Clizin(s). <br />0 Dispenser Containment FlmKs) and <br />[I Shear Valve($). <br />El Dispenser Containment Floats) and Chain(s). <br />*If the facility contains More tanks or dispensers, copy this form. <br />Include information for every tank and dispenser at the facility. <br />C Certification - I ecrt* tbat the equipment identified <br />in this document was inspected/serviced in accordance with the manufacturers' <br />.guidelines. Attached to this Certification I$ information (e g. manufacturers' checklists) necessary to verify that this Information is <br />bove <br />corirciet and a 8fte-091-Plan Showing the layout of monitoring aipment. For any eqdipment capable of generating such rsportsj <br />also attached a copy of the report; (check all that aPPIW: <br />system set -UP Alarm history rep <br />- r 'o'y f - <br />Technician Name (print)' - EWIND BYE.. <br />signature: — rC <br />certificatioILNo., 8143703 <br />License. oe 779267 <br />Testing company Name: - LC SERVICES <br />Phone No 559) 444-1730 <br />Testing company Address: 3887 N. VALENTINE FRESNO CA. 93722 Date of Testipg/Servicing: 01612014 <br />UN -036 -1/6 <br />www.unidoes.org Rev. 01/17M <br />