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Ah 10 RECEIVED MONI_TOFB NG SYSTEM nCEtRTIFICATION NOV 2 0 2014 or Use Ali Jur dictiow the ate of Aarhoriry Cited:Chapter 6.7,Health and Safety Code, fornia Chapter 76, Division 3, Title 23,Cali�P /�®FI i�Pf�t- '.HEALTH This form must he used to docmnent testing and servicing of Monitoring equipment A scoa[ele der5ifcation or^e n muniy)rina system control noneI by the technician s+ho perfofma the work. A copY of this farm mutt be provided to the tank system ownnr/operator, 't'he ownerloperator must submit a copy of this lout L to the local agency regulating UST systems within 30 days of test dote. A. General Information Bldg.No.: Facility Name: Wino Country 76 _ City: Lodi,Ca. Zip: 95240 Site Address: 1111 E. Kettleman Ln. Contact phone No.: (209) 369.3633 FacilityCOMWAPUSOn: Sonnle Date of Tc9tinglServiciriF 1012212014 Make/Model of Monitoring System: Gilbare' EMC B. Inventory of]Equipment Tested)[Certifted Cheek thea re rias bases totaaicatc specific a ul melt inspeetcNatrvieed: f[g k to: Ti: 67 Tank to: T2s 91 -Tank Gauging Probc, Model: ❑1n-teak Gauging Probu Modal'. nutar Space or vault Sensor. Modd: 794391.420 Annular Spaca Or Varil Senmr. ModelPAOMB114a000 aPlit•18nk iplog Sump/'finish Sensa[(s). Mudd: PA02592000D10 ®Piping Sump f Tsrnch Sensor(s). yMl ;: PA023920r1U IS iill Sump Sensor(s). Morel: Q,�r Fi115ump Sansns(a)echuWLinel.mkDetector. Model: 99Lo;!000 yMECbalcaSlineLeakDetetor. MndeI: FEPetroFEPetroaT lcctrooiu l.me Leak'Dctcslo*. Madel: ❑Eiccnonicl.ine Leak Director. Modelurk OwerfD l High-[.cad Saesor. Model:` ❑Tank Overfill!High-Level Sensor. Model: And model in Sectias E on PBS 2). ❑()Oso(specify cquipmrnt type and tootld in section on Page 2). C]Olher(specify c4uipment ifs Tank ID: Tank ID: T3: Diesel Model ❑to-Tank Gauging Probe. Model' ❑AnnulaIn-Tookr GaugingrProbe. ®Annnlarspecearvadtsensor. Modal•. PA02:911440005pIfttank ❑fjp!rSsumc/T¢hlSmus T(S)t Sooner. Model: ( Piping Sump 1 Trcnch Searm(s). Mode(: PAD21i9200001 O Q pip g' P Modd: ❑Fill Sump Scnsor(s)- Model. ❑Fill Sump Scnsor(s). ❑Mechanical Linc I.enle Detector. Model ®Mechmicai Line t.tnk Detector. Model: tell 2000 ❑Eleeooatc liz I Aak Detector. Mader ❑Elcoannic line Leak Deteuor. Moder ❑Tank Overfill 1 High-level Samar. alodct ❑Tank Gverfif/ quIpmeve]pe and MWei: i and model in Secuer E on page 2). ❑Other(specify cquipr„rnt type end model in Sedion E tot Pagc Z}. ❑othtc(spcaitye4s^i'� tips Dispensr+ID: 3&4 Dispenser ID: 1&2 ❑Dispenser Custainment Sansor(s). Model: ❑nispesser Contninmm[a mor(s). Model: SheQVdve(s). 2 Shear Valvels), ®IJisper a Coma arrest noa1(o)and Qtain(s). ®t)ispcnaet Coankament Flaat(s)and Chain(s). ._ th"enser ID: 5d'6 Disponscr lD: 7&6 Madel: []rHspensumContainmeSm'ur(s). Mader , ❑DE9prnscr Conlunmem Senshr(s). 0 Sktar valve(s). ®Shcm Var Con. �Dispetacr Conlaiammt Floats)and C►esn(s). ®Unpenuantainmem Float(s)and Chain(s), Dispenser ID'. Dispenser ID: ❑Dispenstt Conlainmcnt Sunsor(s). Modd: _ ❑Dispenser Contuinmeed Semor(s). Model:,_ ❑Shaa vaNe(a} ❑showvaiwe(s) ❑P Shear uar Cotldinmenl Flwt(t)and Cnein(s). ❑Dlspoascr Containment IFINA(s)and Chain('). elf the facility conuun9 more tank+or dispenser..,copy thin form. Include inCormstion for every tank and dispenser at the facility. th the C. Certiftealion • I cerBfy that the equipment identified in this document was inspected/serviced in accossrY rdance that this manafaeturers' gaidlelines. Attached to this Cartlfication is infOfmatino (e.g. manufacturers' ecoluf Ment �stsil "Pablo o[generating such information Is correct and a Plot Plan showing the layout of monitoring ago' meet. For any eq W g System set-up Alarm history report npor>a,I kava sun athcbed a copy of Il a report;(ai+erk aG that apply): �� Technician Name(print): Guadalupe Sanchez Signs! CertificaiionNo.: A30138 License.No;- 683706 Phone No.:(209) 845-8586 Testing Company Name: Reliable PtrtnYleum Setvlees,lac. Date of Tessin ervicing: 1012212014 Testing Company Address: i1t330 Hors,9shoe Rd.Oakdale Ca-95361 Page 1 of 4 Rev(2106) Z C9689VS60Z wnelahedelgeiley e££'bOVIOZ^oN