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07r3nknok)9y ONITORING SYSTEM CERTIFICATION 11 se By All Jurisdictions Within the State of Califon Authority Cited:Chapter 6.7,Hea th and Safety Code;Chapter 16,Division 3 Title 23 alifomia Code of Regulations This 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 certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this toren 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: USA#65 City: LODI CA Zip:95242 Site Address: 2500 W.LODI AVE. Contact Phone No:333-9834 Q LOWER SACRAMENTO RD. 11/06/2003 Facility Contact Person: MGR-SHARON Date of Testing/Service: Make/Model of Monitoring System: VEEDER ROOT TLS Work Order Number: 2228896 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: SUPER Tank ID: DIESEL X In-Tank Gauging Probe. Model: MAG 1 X In-Tank Gauging Probe. Model: MAG 1 X Annular Space or Vault Sensor. Model: 794390-420 Annular Space or Vault Sensor. Model: 794390-420 -571 Piping Sumprrrench Sensor(s). Model: 794380-208 Piping Sumprrrench Sensor(s). Model: 794380-208 X Fill Sump Sensor(s). Model: 794380-208794380-208 Fill Sump Sensor(a). Model: Mechanical Line Leak Detector. Model: FX1 V Mechanical Line Leak Detector. Model: FX1DV 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: X In-Tank Gauging Probe. Model: MAG 1 E In-Tank Gauging Probe. Model: MAG 1 X Annular Space or Vault Sensor. Model: 794390-420 E Annular Space or Vault Sensor. Model: 794390-420 X Piping Sumprrrench Sensor(s). Model: 794360-208 Piping Sumprrrench Sensor(s). Model: 794380-208 XIFill Sump Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: 794380-208 X Mechanical Line Leak Detector. Model: FX1 V Mechanical Line Leak Detector. Model: FX1V 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 : 1-2 Dispenser ID: 4-5 X❑Dispenser Containment Sensor(s) Model: 794380-206 X Dispenser Containment Sensors) Model:794380-208 XJ Shear valve(s). X Shear Valve(s) 0 Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 7-8 Dispenser ID: 6 XQ Dispenser Containment Sensor(s) Model:794380-208 Dispenser Containment Sensoria). Model:794380-208 IShear Valve(s). Shear Velve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3 Dispenser ID: QDispenser Containment Sensor(s) Model:794380-208 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 forth. 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 cored. and a Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,1 have also attached a copy of the(Check all that apply): System set-up report; F-1 Alarm history report El PRINTED NAME:ANEIL CHAND SIGNATURE: COMPANY: Tanknolony PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01