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MONITORING SYSTEM CERTIFICATION 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.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 system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Geroge Kishida Inc County: San Joaquin Site Address: 1725 Ackerman Dr City: Lodi Facility Contact Person: Contact Phone 209-368-0603 Make/Model of Monitoring System: Omnitec Date of Testing/Servicing: 11/17/2017 B. Inventory of Equipment Tested/Certified Tank ID: DSL-1 Tank ID: DSL-2 ®In-Tank Gauging Probe. Model: mag ®In-Tank Gauging Probe. Model: mag ®Annular Space or Vault Sensor. Model: optic ❑Annular Space or Vault Sensor. Model: split ®Piping Sump/Trench Sensor(s). Model: optic ®Piping Sump/Trench Sensor(s). Model: optic ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: FXIDV ®Mechanical Line Leak Detector. Model: FXIDV ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑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). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model. ❑In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑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: I Dispenser ID: 2 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ®Shear Valve(s). ®Shear Valve(s). ®Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser ID: SAT Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ®Shear Valve(s). ❑Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). DiLLD ser ID: Dispenser ID: nser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: Valve(s). ❑Shear Valve(s). nser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Check the appropriate boxes to indicate specific equipment inspected/serviced: 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 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(print): Rhome Desbiensq Signature: Certification A22883 License No.: 433159 Testing Company Name: B.Z. Service Station Maintenance Phone No.: (916) 371-2380 Site 1041 Triangle Court West Sacramento,CA 95605 Date of Testing/Servicing: 11/17/2017 Monitoring Certification Test Report I of