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,Z9AM^�`—fir- � MONITORING SYSTEM CERTIFICATION Use By All Junsdictions Wifhin the State of Califo Authority Cited:Chapter 6.7, Ith and Safety Code;Chapter 16,Division 3 Title 2-1,RWitbmia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monhoag system control panel is installed at the facility,a separate the technician who performs the mrk. A y of this form system homer/operator.uTheeovvneroperetor ured for ea, slwwdbmd a copy of this form to the local agency regulating UST systems within 90 days of test datet provided to the tank A.General Information Facility Name: USA#65 City: LODI CA Zip:95242 Site Address: 2500 W.LODI AVE. Contact Phone No:333-9834 @ LOWER SACRAMENTO RD. Date of Testing/Service: 09129/2004 Facility Contact Person: MGR-SHARON Make/Model of Monitoring System: TLS-350 Work Order Number: 2232464 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 1-87 Tank ID: 2-89 X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: LS3 — Annular Space or Vault Sensor. Model: LS3 X Piping Sump(Trench Sensor(s). Model: 206 Piping SumprTrench Sensor(s). Model: 206 X Fill Sump Sensor(s). Model: 206 Fill Sump Sensor(s). Model: 206 Mechanical Line Leak Detector. Model: FX1 V Mechanical Line Leak Detector. Model: FX1 V Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overall/High-Level Sensor. Model: Tank Overall/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: I- X In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: MAG -Xj Annular Space or Vault Sensor. Model: LS3 Annular Space or Vault Sensor. Model: X Piping Sumprrrench Sensor(s). Model: 206 Piping SumprTrench Sensor(s). Model: 246 191 Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 246 x1 Mechanical Line Leak Detector. Model: FX1 V Mechanical Line Leak Detector. Model: FXt-DV Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model DTank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). D Other(specify equipment type and model in Section E on page 2). Ispenser : 1/2 Dispenser ID: 3 X❑Dispenser Containment Sensor(s) Model:206 X Dispenser Containment Sensoria) Model:208 X❑Shear Valve($). X Shear Valve(s) Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 415 Dispenser ID: 6 ODispenser Containment Senwr(s) Model:208 Dispenser ContainmentSensor(s). Model:208 X Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Cham(s). J Dispenser Containment Float(s)and Chain(s). Dispenser ID: 718 Dispenser ID: 9 X❑ Dispenser Containment Sensor(s) Model: 206 X Dispenser Containment Sensor(s). Model:208 7 Shear Valve(s). X Shear Valve(s). Dispenser Containment Float(s)and Cham(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. 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 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 report; f-1 Alarm history report X❑ PRINTED NAME:DOUGLAS HARTY SIGNATURE: COMPANY: Tanknolocv PHONE NO: (800)800.4633 page 1 of 3 Based on CA form dated 03/01