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140721-003 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http:llwww.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 owner/operator. The ownerloperator 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 Zip: 95242 Facility Contact Person: dennis Gritsko Contact Phone No.: _ 916-205-9291 MakslModel of Monitoring System: Pnenmercator TN4S 2000 Date of Testing/Servicing: $=1-2014 B. Inventory of Fquipment Tested/Certified Check the appropriate boxes to Indicate specillic equipment Ins ectedlserviced: Tank ID: Die�cl Tank ID: ❑ In-Tank Gauging Probe. Model: a In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: Piping Sump)Trench Semor(s). Model: LS 600 #3 ❑ Piping Sump 1 Trench Sensor(s). Model: p Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: C1 Mechanical Line Leak Detector. Model: t] Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector, Model: O Electronic Line Leak Detector. Model: 0 Tank Overfill 1 High-Level Sensor. Model: ❑ Tank Overfill l High-Level Sensor. Model: 0 Other(specify e ui ent a and model in Section E on Pa 2). 0 Other(specify equipment type and model in Section F on Pa 2). Tank ID: Tank ID: 0 in-Tank Gauging Probe. Model 0 In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: 0 Piping Sump!Trench Sensor(s). Model: O Fill Sump Sansor(s). Model: 0 Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Modal: O Electronic Line Leak Detector. Model: 17 Electronic Line Leak Detector, Model: 17 Tank Overfill i Nigh-Level Sensor. Model: 0 Tank Overfill 1 High-Level Sensor, Model: 1 0 Other(sp2cify equipment a and model in Section.E on Pa 2. ❑ Other fspecify equipment type and model in Section E on Pa 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: CI Dispenser contairrrnant Sensor(s). Model: ❑ Shear Valve(s). 0 Shear Valvets). ❑ Dispenser Containment Floats and Chain(s). A Dispenser Containment Float sl and Chain(s). Dispenser ID: Dispenser 10: ❑ Dispenser Containment Samor(s). Model: _._.____..... ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). 0 Dispenser Containment Floats and Chain(s). 0 Dispenser Containment Floats and Chains. Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s), Model: 0 Dispenser Containment Sensor(s). Model: El Shear Valve(s). 0 Shear Valve(s). 0 Disg2nser Containment Floats and Chains 0 Dispenser Containment Floats and Chains. '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 InspectedlservIced In accordance with the manufacturers' guidelines. Attached to this Certification Is Information(e.g.manufacturers'checklists) necessary to verity thatthis Information Is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable f ��L9u islm't D ,ep fir YY Ih�Ahave also ttached a copy of the report;(check all that apply): 0 System set-up 0 Alarm history rep I 9 9 1 Technician Name(print): David Smith Signature: OBIT201418:08:14 Certification No.: 229013 License.No.: 703190 Testing Company Name: Sunwest engineering Inc. Phone No.: 9( 09 )594-9850 Testing Company Address: 4780 cheyenneway chino Ca.91710 Date of Testinoarvickfg: 8=1-2014 Monitoring System Certification Page 1 of 4 12(07 QA/QC APPROVED 8121/201411:10 AMM ikeP- B 1 2121/07