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MONI RING SYSTEM CETIF r.ATION 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 date. A. General Information FLAME LIQUOR - MINI MART Facility Name: 1301 W. KETTLEMAN LANE Bldg. No.: LODI, CA 95242 Site Address: Zip: Facility Contact Person: , / Contact Phone No.: y C'4 ✓1'�� Date of Testin Servicin Q / 25/(�J Make/Model of Monitoring System: �-y g/ g: B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to fadleate s eclflc td ment ins ected/servlced: Tank ID: Tank ID: allf In -Tank Gauging Probe. Model: yytoecl In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: t/2701 1 Piping Sump / Trench Sensor(s). Model: 2. Piping Sump / Trench Sensor(s). Model: a_0'8'" ❑ Fill Sump Sensor(s). Model: _ ❑ Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 111— Mechanical Line Leak Detector. Model:" ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 1W Tank Overfill / High -Level Sensor. Model: 10 Tank Overfill / High -Level Sensor. Model: r ,aA - ❑ .Other ec' ent = and model in Section E on Pa Le 2). ❑ Other ent = and model in Section E onP e 2). Tank ID: Tank ID: ra In -Tank Gauging Probe. '--Model: m _ ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: _ 6 °.,. ❑ Annular Space or Vault Sensor, Model: Piping Sump / Trench Sensor(s). Model: ; , !) ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 1P Mechanical Line Leak Detector. Model: M ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: U Tank Overfill / High -Level Sensor. Model:` ❑ Tank Overfill / High -Level Sensor. Model: ❑ Otheri ui ment and model in Section E on Page 2). ❑ Otherui ent a and model in Section E on Page 2). Dispenser ID: 1- a-.. Dispenser ID: —7- r ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Di enser Containment Flo!%s) and C s . Di!Mer Containment Flo 22 and C s . Dispenser ID: 7 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). D' er Containment noa4 and C s). ❑ Di&a= Containment Floa s2 and s . Dispenser ID: b -. Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Valve(s). ❑ Shear Valve(s). VShear sEEser Containment Fl s2 and C s). ❑ DigEwer Containment Fina s2 and C 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 equipm"! For any quipme t capable of generating such reports, I have also att4f d a copy of the report; (check all that apply): G Sy set- !� Alarm history report Technician Name (print): 1Sob tai e.IMCIJ Ci Signature: Certification No. License, N9,; 79 Testing Company Name: "T.AANNK-TEK ENVIRONMENTAL CORPORATION Phone No.: (707) 446-6151 Site Address: ) W 1 Cil t °�((V1 m bw [, Date of Testing/Servicing: / 25/0� Page 1 of 3 03/01 Monitoring System Certification