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140224-441 Appendix VI (Copies of Monitoring System Certification forms and UST Monitoring Plot Plan available at hftq_llwww.waterboards,ca.gov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Califomia 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 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 Terns(Intl) _ Bicig.No.:LODICA Site Address: ?500 West Turner Road _ City: Lodi Zip: 95242 Facility Contact Person: Dennis Gritsko Contact Phone No.: (916)205-9291 Make/Model of Monitoring System: Pneumercalor TMS 2000 _ Date of Testing/Servicing: 4/9/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicatespecific Nuipment ins ected/serviced: Tank ID: Die-cl 'Tank ID: In-Tank Gauging Probe. Model c 4 r>>t :, ,, ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: L5610 - - - - - E3 Annular Space or Vault Sensor. Model: ---- - -- — Piping Sump I Trench Sensor(s). Model: 1.5600 ['-i 0 Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ____ 0 Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 0 Electronic line Leak Detector. Model: Tank Overfill I High-Level Sensor. Model: RS 2r Mechaniral 0 Tank Overfiil I High-Leve]Sensor. Model: ❑ 01her(specify equipment a and model in SectionE on Pa 2). El Other(specify equipment type and model in Section E on Pa 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor, Model- 0 Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump I Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: _ ❑ Electronic tine Leak Detector, Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill I High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Other(speclfy a moment type and model in Section E on Pa 2). 0 Other(specify eqLjiprrent type and model in Section E on Page 2). Dispenser ID: —_—_ Dispenser ID: ❑ Dispenser Containment Sensor(s). Model:-_ —. M Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s) 0 Shear valva(s). 0 Dispenser Containment Floats and Chains. 0 Dispenser Containment Floats and Chain(s), Dispenser 10: Dispenser ID: 0 Dispenser Containment Seasor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). a Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s), Model: 0 Dispenser Containment Sensor(s). Model: 1❑ Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Floats and Chains 0 Dispenser Containment Floats and Chain(s). _ 'N the facility contains more tanks or dispensers,copy this iorm. Indude information for every tank and dispenser at tho facility. C. Certification - I certify that the equipment identified In this document was Inspectedlservlead 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 Plot Plan showing the layout of monitoring equipment. For any equipment capable of enerating such reporrts�`II have ggalso�attached a copy of the report;(check all that apply): System set-up Alarm history reporLD i �gied bV Tadd Hansen for IY 1}114022(,441 Technician Name(print): Todd Hansen Signature: 2 7 11 Conlication No.: 8045710 License.No.: 703190 Testing Company Name: Sun West Engineering Inc. Phone No.: 9( 09 1594-9850 Testing Company Address: 4780 Cheyenne Way Chino,CA 91710 Date of Testing/Servicing: 4/912014 Monitoring System Certification Page 1 of 4 12107 QAIQC APPROVED 4/10/201411:21 AMMlike P. B 1 2/21107