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OCT-27-2003 18:29 CITY OF LODI 209 333 5710 P.44 J i•w v� r ..- �, a I� tt LA F se By.411 Jurisdiclions IT"ithin the.Stole of Cali icr I A t 4ul'horin)Cited: Chapter 6 7. N, and Safety Code:Chapter 16. Division 3, Till, California C 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 Danel 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 Xnformatiotl Facility Name: 0& Bldg,No.: Sire Address: 1371 S. AA161 t'_.j City: L,:eA I' Zip, Facility Contact Person:-_ ,'yi^'`Z S _ Contact Phone No.: ( 20 ) 3,3'3 - L �'r✓ Make/Model of Monitoring System; V u(r,.� fkaA- -W --2S-0 Date of Testin,g/Smicing: �/�/ CLer R Inventory of Equipment Tested/Certified Cheep the appmpriate boxes to intlicate specific equlZment inspected/serviced: T. k ID: v► Tank ID: p1 G n-Tank Gauging Probe. Model: 132!Zjd In-Tank Gouging Prone. Model:l�i/ _ Annular Space or Vault Sensor. Model: �'t JiAnnulor Space or Vault Sensor. Model: YZ4) Piping Sump/Trench Sensor(s). Model; jid Piping Sump/Trench Scnsor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: [f Mechanical Line Leak Detector. Model-..; Z"G) � Mechanical Line Leek Detector. Mode /n+✓ea .AJ ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tonk'Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Page 2). O Other(Spect equipment a and model in Section E on Pae 2).. T nk ID: S Trtnk ID: n-Tank Gauging Probe. Model: AVW Cl In-Tank Gauging Probe. Model: nular Space or Vault Sensor. Model: YJ at ;xArinular Space or Vault Sensor. Model- f�0 Piping Sump/Trench Sensor(s). Model: WPiping Sump/Trench Sensor(s). Model:_ ❑ Fill Sump Sensor(s). Model- ❑ Fill Sump Sensor(s)- Model: ❑ Mechanical Linc Lcak Detector. Model: O Mechanical Line Leak Detector. Model: Q Electronic Linc Lcak Detector. Model: O Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: Tank erfill/High-Level Sensor. Moclel:t'yfiZ , ❑ Other(specify equipment a and model in Section E on Page 2). ❑ Other(s eci a ui meat t c and model in Section on Page 2). D' er ID: 1 -7, fp 1- t CIL- Dispenser ID: Dispnsenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: PShear Valve(s). 13,Shear Valve(s). OID i nser Containment Float(s)and Chnin(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: O Shenr Valve(s). ❑ Shear Valve(s). Q Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Con4iinment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Scnsor(s), Model: Cl Shear Valve(s). ❑ Shear Valve(s). CID is enser Containment Float(s)and Chain(s). 1 ❑ Dispenser Containment Float(s)and Chain(s). 'Ifthe facility contains more tanks or dispensers,copy this fo Iriclude inforniatio fry or every ptank and ispen_ er pt the faeiiity. C. Certification - i certify that the equipment ide Yred in this doeumen was inspectedd//ssen%)riced 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 tihuwing the layout of monituring equipment. For any equipment enpabie of generating such reports,I have also attached a copy of the report, (check af/that apply): XSymems p Alarni history report Technician Name(print)' IL 12 1 �'� le- Signature: lc'_L' i:p 52(0 3 1/r Certification No_: yf`7� License.No.: -/ Testing Company Name: C i� l F75>" Phone No.:( .ZOG Site Address:' / ?i' �, �i�A-r' G.J Date of resting/Scrvicing: 1111;rC I of 3 f1.t/u I Niouitorin(Syslem Certification