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MONITORING SYSTEM CERTIFICATION r or Use By All lurisrlicdprts Within the State o f Cgt{f orr:ia Authority Cited. Chapter 6.7. Heal* and Sgfety Code. ;thapter 16, Division 3, Yale 23, Californic Code of Regulariau This form mostbe used to documeR� testing and servicing of monitoring equipment A separate mortification or report must be pMnared for each monitoring systems control pmtel by the technician who performs the work. A copy of this form trust 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 In€ormatia FLAME LIQUOR- MINI MART Facility Name: 1301 W. KETTLEMAN LANE Bldg. No.: Site Address: LODI, CA 95242 Zip; Facility Contact Person:. Contact Phone No. n/ Make1Mode1of Monitoring System: = Date of Testing/Servicing: ( F-1-it_ll-21/� B. Inventory of Equipment Teste&CerUfied ,-aem we a ro SLC DOYtS Iw rrror u rC menr ceorserncea: T ID: Tank ID: Tank Gauging Probc. Model: @9In-Tank Gauging Probe, Model: Annular Space or Vault Sensor. Model: 1�1AttnuW Space or Vault Sensor. Model: Prpurg Sump / I3> nch Sensor(s)-Madsl: Piping Sump / T=ch Smmr(s). Model: 01 Fill Sump Scasor(s), Vlet inanicai Line Leak Detector. Mndel: Model 0 Fill Sun+ Seusor(s). tWMechaujcd Line i ca><Detetxnr. Model:----- Model:! i 0 Electronic Line Leak Detector, Model:: U 81octm;nic Line Leak Detector. Model: Q Tank Overfill / Mgh-Level Sensor. Model: Cl Tank Overfill ! High-Leviel Sensor. Model: Q Odw (specify equiementopo and model in S-ection 5 on P 2 . Q Outer. ui mcut i and model in Section E on Pae 2). 'Tank`uh TsnkID: 0 -b -Tank Ganging Probe. oaoI:Atll Qin-Tann £iaugiag Probes Model: p*Ar wular Space or Vdo)t Sensor. 'ipiAg Sump /Trench 5ensor(s). Model:4 U> Modal: Cl A.W. Space Or Verb .S'drW'OP. Q Model: Piping Sump / Tm"h Sensor($). Model: Cl Fill Sump Sensor($). Ji�. lechanieal Line Lta)t Detector. Model: _ Model: Q Fill Sump Seasm(s). Q Mechanical Lbe 1=k Detector. Model Model: Z} ElectrouiclSaaLealcl�etoaor. Model: Q E1o=,ut1oUne.LaakDct=or. Model: Q Tank Overfill / Hith-Level Sensor. Model: _ 0 Tank Overfill 1 Weigh-Lavel Sensor, Model: C! Olhcr eci i t and model .in Section E on Pette 2). Q Othmr (s and model in Section E on Pase 2). Dispenser ID: Dispenser ID' - O Dispenser Containment Sensor(s). Model: Cl Dispa= Conta nzent Sensor($ . Model: ;Shear Valve(s). Shear 119 s Containment HoWel and Chain(s). Di ser Containment Hoar s and Chain(s). D easerM. — Alsptatserw. Q Dispenser Containment.Sensor(s). Model; Q Dispenser Conudnnteat Sensor(s). Model Shear Valvo(s). O shearvalro(s). Di nser Containmtent Pl s) and Chain(s). Q Disp== Containrriant Floats . and Chain(s). D ID: 2B Dispcnsec Containment Seasor(s). Model: U Dispenser Cwtainment Sensor(s). Model: Shear Valve s 2jMser Containment Fioat(s and Chain($ . (2 Di ser Containment Rout(s) and Chain(s)- -u the tacunty concerns more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility, C. Certification .I certify that the equipnvut idenffied in this document was iwected/sex-vk-ed in Wcordance with the manufacturers' guideiiues. Attached to this Certincatim Is hdarmatim (eg w2naNemreW c:hwkasts) necessary to Verify that this iui'on intim is correct and a Plot Pian showkg-the bryout eInwaituxtmg equQmnetx. FwRoy ecapsbde of grog such repooris, i have also attached a copy of the rep" (check est apgiy): (Z5ystem set-up Alarm history Technician Name (print): �'� S Signature: Certificationh'o.: 4*;"5 42'L License.Z-- Testing - Testing Company Name: �. --71 *K�� .Phoner%O'% Siwe Address: Data of Testing/Senicing� Monitoring 8VAP-M Cermcati n v 001