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MONARING SYSTEM CERTIFISATION For Use 4y 1111.1urisdielions Within the State ql'California Authority Cited:-Chapter 6 7, Health and Safely Code: Chapter 16, Division 3. Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. 41+e44-L44y�. A scoarate certification or reLort must be orel2ared for each monitoring systgp_Kqq!UjLRqn!j!by the technician who'perl'onns the work. A copy of this form must be provided to the lank system owner/operator. The owner/operator must submit a copy of this lorm to the. local agency regulating Us,rsystems within 30 days of test A. General Information Facility Name: H&M KWIK SERVE BW98 Bldg. No.:_ Site Address: 2501 E.JACKSON City: MODESTO Zip: 95320 Facility Contact Person: MIKE Contact Phone No.: (209) 838-3971 Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 8/3012017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecifec equiemeni inseected/servicedl: Tank : 87 Tank ID: 91 in-'rank Gauging Probe. Model: VEEDER ROOT In-Tank Gauging Probe. ModcL VEEDER ROOT Annular Space or St!nF^r. 420 Annular SpacenorVault Sensor. Model: 420/SPLIT ED Piping Sump/,rrench Sensor(s). Model: 208 JZ Piping Sump/Trench Sensor(s). Model: 208 El Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: RED JACKET FX1DV Mechanical Line Leak Detector. Model: Wit LD2000 ❑Electronic[.me Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Tank Overfill/high-Level Sensor- Model: VEEDER ROOT 01'ank Overfill/high-Level Sensor. Model: VEEDER ROOT ❑Other f1specify equinmeni ivneand model in Section Fon Page 2), r--1 Other(specify equipment type and model in Section 1:oil Page 2). Tank ID: DIESEL Tonkin: 0 In-Tank Gauging Probe. Model: VEEDER ROOT El hi-Tank Gauging Probe. Model: [D Annular Space or Vault Sensor. Model: 420 El Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 208 El Piping Sump/1'rench Sensor(s). Model: E]Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: RED JACKET FX1DV 0 Mechanical Line Leak Doector. Model: 0 Electronic Line Leak Detector, Model: n Electronic[,me Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: VEEDER ROOT 13 Tank Overfill/High-Level Sensor. Model: El Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section Fon Page 2). Dispenser ID: 112 Dispenser ID: 314 El Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: Shear Valve(s). [D Shear Valve(s). Dispenser Containment Float(s)and Cham(s), ED Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Modcl: El Shear Valve(s). U Nnear'Valve(s). 171 Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: El Dispenser Containment Sensor(s). Model- F-1 Dispenser Containment Sensor(s). Modcl: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). *lfthe facility contains more tanks or dispensers,copy this form. Include information for ever),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 S4e-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 till that apply): System set-up Alarm histor, re rt Technician Name(print): PETER WESTBROOK Signature: Certification No.: B46675 Ucen,,c, N, Testing Company Name: L.C.SERVICES Phone No.:(569) 444-1730 Testing Company Address: 3887 N VALENTINE FRESNO CA 93722 Date of Testing/Servicing: 8/30/2017 UN-036—1/6 www.iiiiidocs.org Rev.01/17/08