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IL E UIP ENT SERVJI Division of Keith A. Tallh% Inc. STATE LICENSE No, 323417 CLASSIFICATION: A-11<AZ., C611140 STATEVIRONMENTAL ASSESSOR No. 01781 Telephone: (209) 754-I WS Fax: P" 7545726 Post Ofte Box 950 750 Indtaitrlal Way SAN ANDREAS, CALIFORNIA 95249 'Fills form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, 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. Instructions are printed on the back of this page. A. General Information Facility Name: Norms 76 Bldg. No.:. Site Address: 633 E. Victor Rd. City: Lodi In -Tank Gauging Probe. Model:7-642307- Zip: 95240 Model: 7 6 4 2 9 0 - Annular Space or Vault Sensor. Model:RSDF Facility Contact Person: Gregg Wilson Contact Phone No.: (2 0 9 )367-1795 Make/Model of Monitoring System: TLS 250 I Veeder Root Date of Testing/Servicing: 11 / 4 /0 2 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 1 Sumer Tank ID: In -Tank Gauging Probe. Model:7-642307- (N In -Tank Gauging Probe. Model: 7 6 4 2 9 0 - Annular Space or Vault Sensor. Model:RSDF IR Annular Space or Vault Sensor. Model: R SDP 111 Piping Sump/Trench Sensor(s). Model:7 6 4 3 0 0- 2 0 5 IX Piping Sump/Trench Sensor(s). Model: 764'100-20-9 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model:RJ F X 1 V IR Mechanical Line Leak Detector. Model: RJ FX1 V ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: M Tank Overfill / High -Level Sensor. Modcl:OPW61 -SODrop/ (X Tank Overfill / High -Level Sensor. Model: OPW61—SODrop / ❑ Dispenser Containment Sensor(s). Model: Tube ❑ Dispenser Containment Sensor(s). Model: Tl3be §1 Shear Valve(s). IR Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). (M Dispenser Containment Float(s) and Chain(s). ❑ Other (s ecif equipment a and model in Section E on Pae 2). ❑ Other (specify Sguipment ty2c and model in Section E on Page 2). Tank ID: 3.. Reg Tank ID: Xl In -Tank Gauging Probe. Model:7 6 4 2 9 Q_— 3 0 7 ❑ In -Tank Gauging Probe. Model: X) Annular Space or Vault Sensor. Mode1:RSDF ❑ Annular Space or Vault Sensor. Model: X) Piping Sump/Trench Sensor(s). Nlodcl:7 6 4 3 0 Q — 2 0 5 _ ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: XI Mechanical Line Leak Detector. ModclRJ FX1 V ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Xl Tank Overfill / High -Level Sensor. ModelEMCO All 00/ ❑ Tank Overfill / High -Level Sensor. Model: ❑ Dispenser Containment Sensor(s) Model: Dro_p__Tube -❑ Dispenser Containment Sensor(s). Model: a M Shear Valve(s). ❑ Shear Valve(s). _ 10 Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chains). ❑ Other (specify equipment t e and model in Section E on Page 2). ❑ Other (s ecifv equipment a and model in Section E on Page 2). 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 Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports. I have also attached a cope of the (check all that applt): ❑ System set-up report; ❑ Alarm history rWort. Technician Name (print): -James P. Hesketh Cert./Lic. No.: 6-0669 Signature: Testing CompanyNarne: _ Oil Equipment Service Phone No.: 20 )7 -1808 CALM -01 P•„,,, t