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r , i.avi a a Vahai ,V l) l /J 1 JJlTi \.2-J1.Ll it A%-,, X aiVl For By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7, Head Safety Code;Chapter 16, Division 3 Title 23, Cal Code of Regulations s form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility,a separate rtification 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 >tem 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. General Information icility Name: ARCO 02076, CC 18022641 City: LODI CA Zip: 95240 to Address: 800 KETTLEMAN LN Contact Phone No: 334-3678 PTO N-85 Date of Testing/Service: 05/02/2007 icility Contact Person: MANGER ake/Model of Monitoring System:TLS-350 Work Order Number: 2248888 Inventory of Equipment Tested/Certified Teck the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 91 Tank ID: 87 MASTER X In-Tank Gauging Probe. Model: MAG Q In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 407 X Annular Space or Vault Sensor. Model: 407 X Piping Sump/Trench Sensor(s). Model: 323 ❑X piping Sump/Trench Sensor(s). Model: 323 X Fill Sump Sensor(s). Model: 323 Fill Sump Sensor(s). Model: 323 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: ELECT. X ❑ Electronic Line Leak Detector. Model: ELECT. X Tank Overfill/High-Level Sensor. Model: MAG ® Tank Overfill/High-Level Sensor. Model: MAG 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: 87 SLAVE TanklD: In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 407 Annular Space or Vault Sensor. Model: 407 X Piping Sump/Trench Sensor(s). Model: 323 X Piping Sump/Trench Sensor(s). Model: 323 _X1 Fill Sump Sensor(s). Model: 323 ❑X Fill Sump Sensor(s). Model: 323 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: MAG ® Tank Overfill/High-Level Sensor. Model: MAG Other(specify equipment type and model in Section E on page 2). ❑ Other(specify fyequipment type and model in Section E onpage 2). Ispenser : 1-2 Dispenser ID: 3-4 0 Dispenser Containment Sensor(s) Model:323 X Dispenser Containment Sensor(s) Model:323 X❑Shear Valve(s). X] Shear Valve(s) ❑Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 0 Dispenser Containment Sensor(s) Model:323 . Dispenser Containment Sensor(s). Model:323 X❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 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). *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. 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 Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports, I have also attached a copy of the(Check all that apply): System set-up X❑Alarm history report e .�, a chnician Name(print): DENNIS RUE Signature: !rtification No.: 006-05-1510 License. No.: sting Company Name:Tanknology Phone No.: (800)800-4633 e Address: 8501 N. MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 05/02/2007 Pana 1 of.1 acarl nn('A fnrm riatarl wvn1