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MONAkRING SYSTEM CERTIFICRTION For Use By All Jurisdictions Within the State of California Authority 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 equipment. If ffime am onem�m ^t t'� a-A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank s6 The 12 for must submit a copy of this form to the local agency regulating UST.systems within 30 days of test date. age- A. General Information APR 12014 � Facility Name: PILOT#617 Bldg.No.: . Site Address: 15100 N THORNTON RDEw/innlawcwl Zip: 95240 Facility Contact Person: JERROD HERRONDEPARn ac l ne No.: 1(209) 339-4022 IE Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing:4/7/2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate=Lc in went ins cted/serviced!: Tank ID: SUPREME Tank ID: UNLEADED TANK 1, UNLEADED TANK 2 -Gau&g Rrobe Model- — - be_ -- l- MAGIi ®Annular Space or Vault Sensor. Model: BRINE DUAL FLOAT ®Annular Space or Vault Sensor. Model: BRINE DUAL FLOAT ®Piping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 ®Fill Sump Sensor(s). Model: 208 IR Fill Sump Sensor(s). Model: 208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Seng. 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: UNLEADED TANK.3 Tank ID: UNLEADED TANK 4 ®In-Tank Gauging Probe. Model: MAGI ®in Tank Gauging Probe. Model: MAGI ®Annular Space or Vault Sensor. Model: BRINE DUAL FLOAT ®Annular Space or Vault Sensor. Model: BRINE DUAL FLOAT ®Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208 ®Fill Sump Sensor(s). Model: 208 IR Fill Sump Sensor(s). Model: 208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model- ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Levet Sensor. Model: FLAPPER ®Tank Overfill/High-Level Sensor. Model: FLAPPER k ❑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, 3-4,5-6 Dispenser ID: 7-8,9-10,11-12 ®Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containment Sensor(s). Model: 208 ®Shear Valve(s). ®Shear Valve(s). i ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 13 Dispenser ID: 1445 ®Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containment Sensor(s). Model: 208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 16-17 Dispenser ID: 18 ®Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containment Sensor(s). Model: 208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(!)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' guidelines. Attached to this Certification is information(e.g.manufacturers' checklists)necessary to verify that this information is correct and a Site-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 set-up ®Alarm history report Technician Name ADAM TAYLOR Signature: Certification No.: 838383,8143455, License.No.: 6304147 Testing Company Name: FRANZEN-HILL Phone No.:(559) 688-2977 Testing Coj%any Address:1100 N J STREET TULARE CA 93274 Date of Testing/Servicing:4/7/2014 I