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130312-737 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plat Plan available at hitp://www.waterboards.ca.gov.) 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 ownerloperator. 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: Lodi CA FO Term(Intl) Bldg.No.:LODICA Site Address: 2500 West Turner Road City: Lodi zap: 95242 Facility Contact Person: Dennis Gritsko Contact Phone No.: (916)37313626 Make/Madel of Monitoring System: Prieumereator TMS 2000 Date of Testing/Servicing. 4/10/2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment In ctedlserviced: Tank ID: Diesel 4000yalluns23M Gallons Tank ID: In-Tank Gauging Probe. Model: \tl'4505-088-25 ❑ in-Tank Gauging Probe. Model: Annular Space or Vault Sensor, Model: LS610 ❑ Annular Space or Vault Sensor. Model: Piping Sump!Trench Seasor(s). Model: LS600 (2) ❑ Piping Sump I Trench Sensor(s). Model: Cl Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model. t7 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: p Electronic tine Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill 1 High-Level Sensor. Model: RS 2,Mechanical ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment t e and model in Section E on Pa 2). ❑ Other(specify equipment type and model in Section E on Pa 2). Tank ID: Tank ID: ❑ €n-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Modet: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump 1 Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: R Tank Overfill I High-Level Sensor. Model: 0 Tank Overfill 1 High-Level Sensor. Model: ❑ Other(specity EquiMeni a and model in Section E on Pa 2). 0 Others Ci 2guipment t e aM model in Section Eon Pa 2). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model. 0 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). * Dispenser Containment Floats and Chain(s). O Dis enser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s)Dispenser Containment Floats and Chain(s). E3 Dispenser Containment Floats and Chain(s). spenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). E3Shear Valve(s). Dispenser Containment Floats and Chains 0 Dispenser Containment Floats 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 Inspeetedlserviced In accordance with the manufacturers' guidelines. Attached to this Certification Is information(e.g.manufacturers'checklists) necessary to verity that this information Is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generalting7such u reports{+II have also attached a copy of the report;(chock all that apply): System set-up Alarm history reportDlgWe S geed bU odd f men fof Y4 I#301 L•f.i 7 Technician Name(print): Todd Hansen Signature: 11f11��a 1�.aU.17 Certtflcation No.: 8045710 License.No.: 703190 V+ 1 a0 Testing Company Name: SunWest Engineering Inc. Phone No.: `( 01) )594-9850 Testing Company Address: 2766 Pomona Blvd. Pomona CA 91768 Date of Testing/Servicing: 4110'2013 Monitoring System Certification Page 1 of 4 1 W07 QA/QC APPROVED 411 9120 1 39:46 AMMike P. B 1 2/21107