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MONI *TORING SYSTEM -CERTIFIATION For Use By Alf Jurisdictions Within the St—ateoj ornia Authority Cited:- Chaptet 6.7, Hqalth and Safety Code; Chapter I �, Division 3, 771de 23, Catifornia Code offtulations This form must be usW to document testing and servicing of monitoring equipment. N%Ofa-Alit:1 Asenaratc2Og&WonorrcWrtMMg the TV W I ;I? WT, hE pimared fbr monitoring s3mem-m-n-tr—ol-29W A copy of this form must be provided to the tank system 0,iynertoperator, The owntr/operator must submit a copy of This fbnn to the local regulating UST systems within 30 days of test NO - U I - 11' 1 A. General Information EWRONMENTAL HEALTH DEPARTMENT Facility Name,. H & M KWIK SERV Bldg. No.: Site Addre". 2501 E. JACKSON City: ESCALON Zip: 95320 Facility Contact Person: HASSAN Contact Phone No_ q9l�� Make/Model of Monitoring System, TLS -350 Date of Te-sting/Servicing, 818/2013 B. Inventory of Equipment Tested/Certified 177RUM71h in -Tank Gouging probc Model- VEEDER-ROOT Mitular Space or'Voult Sensor. Model: 420 Piping Sump I Trench Sensor(s). Model: 208 0 Fill Sump Sensor(O Model: R Mechanical Line Leak Detector Model. RED -JACKET Electronic Line Leak Detector. Model, Tank Overfli i High -Level Sensou Modcl� Tank Oveffilt / High -Level Sensor, Tank tD: DIE L Other (specify equipment type and model in Section E on Page 2), 0 In -Tank Gamis Fiiobc model-, Ver:Or=P_ROOT Annular Space or Vault Sensor. Model: 420 piping swop I Trench Sensor(s), Model� 200 ri Fill Sump Sensor(s)� Modt:14 13 Mechanical Line Leak Detector, Model: RED-JAOKET 0 Electronic Line Leak Detector Model: [I Tank Overfill I lRi4h-Level Sensor, Mods]: 0 Other (specify Nuipment " and model in Section E on Page 2). Dispenser 0 Dispenser Containment $cnsorff). Model: Z Shear Valve(s). 0 Dispenser Containment Float(s) and Chaixi(z), Dispenser ID,. ODispenserCfir. italtimentSeMOV(S). Model: 0 Mear Valvc(a). 0 Dispenser Containment Fl=�S) and Chain(s). Tank ID: 91 0 In -Tank Gauging Probe. Model, VEEDER-ROOT 0 Annular Space of Vault Sensor, Model; 420 0 Piping Sump I Trench Sedsor(s). Model! 208 Fill Sump Setiswap 0 Mechanical Line Leak Detector. Model: VMI Electronic Lin', Leak Dcftctor. MC40L Tank Oveffilt / High -Level Sensor, Model: Other (specify equipment type and model in Section E on Page 2), Tank ID: 0 In -Tank Gauging Ptobe. Model: El Annular Space Or Vault Sensor. Model, 0 Piping Sump 1 Trench Strisor(s). Model. 0 Fin Sump Ser r($). model n Mechanical Line Leak OcMW MOdcl� D Electronic Lint Leak Detector - 0 Taok OveriO I / High -Level Sensor. Model: Other (i5pccj6, equipment type and model in Section E on Page 4 Dispenser TD: 3-4 E-] Dispenser Cotatai t Wso*), ModcL 0 Shear Valve(s), Ej DiWenscr Containment Ftoat(s) and Chain(s). Dispenser W, [3Dispenser Containment Sfns*r(5), Model, CQ Shear Valve(s).. Dispenser Containmot floats) and Chain(s). Dispenser ID: ODisp6nwConEWftmcmScAsor(0, Model. Shear Valve($). DiSpe"M Containment Float(s) and Chain(s), mora tanks or dispensers, copy this form. Include 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. manufacturers' checklists) necessary to verify that this information is corm and a Sftetj2t_?19ft showing the layout of monitoring equipment For any equi meet capable of generating such reports, I have also atmelted a copy of the report; (check all that apply)* system set-up Alarm history report Jechilician Name (print)-, JOSEOCHOA Signature: CertiN fication o.: B35931 Lice :tur Testing Company Name: LC SERVICES Phone No.: 669) 4"-1730 Testing Company Address., 3887 N. VALENTINE Date of Testing/Servicir UIN-09 - 1/6 wwwxnidomarg Rev. 0€%€7145