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MONI*RING SYSTEM CERTIFNATION 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 owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test d"R EC E I VED A. General Information �i� FacilityName: Wine Country 76 Bldg.�1f®.LIQ Site Address: 1111 E. Kettleman Ln. City: Lodi, Ca. Zip: 95240 Facility Contact Person: Sonnie Contact Phone No.: (209) 111M UlENTAI HATH Make/Model of Monitoring System: Gilbarco EMC Date of Testing/ServicF*.f0/ft®urms $. Inventory of Equipment Tested/Certified Check the aper2griate boxes to indicatespecific a ui ment ins ected/serviced: Tank ID: T1: 87 Tank ID: T2: 91 ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794390-420 E Anular Space or Vault Sensor. Model: PA02591144000 split-tank ®Piping Sump/Trench Sensor(s). Model: PA02592000010 ®Piping Sump/Trench Sensor(s). Model: PA02592000010 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: 99LD-2000 0 Mechanical Line Leak Detector. Model: FE-Petro STP-MLD ❑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: T3: Diesel Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: PA02591144000split-tank ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: PA02592000010 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: 99LD-2000 ❑Mechanical Line Leak Detector. Model: ❑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 ID: 182 Dispenser ID: 384 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: E Shear Valve(s). ®Shear Valve(s). ®Dispenser Containment Floats)and Chain(s). ®Dispenser Containment Float(s)and Chain(s). Dispenser ID: 586 Dispenser ID: 788 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: E Shear Valve(s). ®Shear Valve(s). ®Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Flom(s)and Chain(s). ❑Dispenser Containment Float(s)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 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 correct and a Plot Plan showing the layout of monitoring eq m meat. For any equipment capable of generating such reports,l have also attached a copy of the report;(check all that apply): System set-up ® Alarm history report Technician Name(print): Guadalupe Sanchez Signature: Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.:(209) 845-8586 Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca.95361 Date of Testing/Servicing: 10/18/2012 Page 1 of 4 Rev(2/08)