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Monitoring System Equi ment Certfflcaii� IP For Use By All Jurisdictions Within The State of California MAR 16 2016 Authority Cited.- Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, 7-11le 23, California Code of Regulations I 1 11 NiETAL lk F --!L This form must be used to document testing and servicing of monitoring equipment. A separate certification orNF 17 \17 �= p=ared for each monito gy5 in !p 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 system within 30 days of test date. A. General Information Facility Name: Mobliffespro Bldg. No.: Site Address: 401 W. Kettleman Ln. City- Lodi, CA Zip: 95240 — Facility Contact Person: Patricia Contact Phone No.: (209) 368-8787 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 2118/16 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Inspectediserviced: Tank e 01 -Regi Tank ID! 02 -Prom [] In - Tank Gauging Probe. Model.- GEICO P 020 [] In - Tank Gauging Probe. Model: GEICO PA2650960200 ll Annular Space or Vault Sensor. Model- VR 7S4390-420 oll Annular Space or Vault Sensor. Model: VR 794390-460 IM Piping Sump % Trench Sensor (q). Model:Kt 71438o-208 N Piping Sump \ Trench Sensor (s). Model: VR 794380,3x8 I] Fill Sump Sensor (s). Model: Ll Fill Sump Sensor (s). Model: N Mechanical Line Leak Detector. Model: KJ116-05" Mechanical Line Leak Detector. Model: RJ 11&05" [3 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: [3 Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High -Level Sensor. Model: [] Other ( specify equipment type and -ode] in Section E on Page 2). ❑ Other ( specify equipment type and model in Section E an Page 2). Tank IQ: Tank IDL_ [3 In - Tank Gauging Probe. Model:- E3 In - Tank Gauging Probe. Model: [3 Annular Space or Vault Sensor. Model: I] Annular Space or Vault Sensor. Model: [3 Piping Sump \ Trench Sensor (s). Model; [I Piping Sump \ Trench Sensor (s). Model: [3 Fill Sump Sensor (s). Model: [3 Fill Sump Sensor (s). Model: [] Mechanical Line Leak Detector. Model: [I Mechanical Line Leak Detector. Model: (3 Electronic Line Leak Detector. Model: [3 Electronic Line Leak Detector. Model: [] Tank Overfill \ Ifigh-Level Sensor. Model: [] Tank Overfill \ High -Level Sensor. Model: I] Other ( specify equipment type and model in Section E on Page 2). [3 Other ( specify equipment type and model in Section E on Page 2). Dispenser IQ-- 01-02 Dispenser IQ: 03-04 13 Dispenser Containment Sensor (s). Model: [I Dispenser Containment Sensor (s). Model: Shear Valve (s). 0 Shear Valve (s). Dispenser Containment Float (s) and Chain (s). if Dispenser Containment Float (s) and Chain (s). Dispenser ID; 05-06 Dispenser III: 07-M [3 Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: Shear Valve (s). Shear Valve (s). Dispenser Containment Float (s) and Chain (s). Dispenser Containment Float (s) and Chain (s). Dispenser IR: Dispenser ID• ❑ Dispenser Containment Sensor (s). Model: [] Dispenser Containment Sensor (s). Model: E3 Shear Valve s). 0 Shear Valve (s). [] Dispenser Containment Float (s) and Chain (s). [] Dispenser Containment Float (s) and Chain (s). *117 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 inspected1serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information (e.g. manufactures' checklists ) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the; (ckcckallifiata. [I System set-up 0 Alarm history report Technician Name (print): Myke Briggs Signature Mfg, CCrt.#.: B38235 ICc# 8033115 -UT License. No.: 485184 Testing Company Name: Service Station §ptems Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 2118116