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OiL EQUIPMENT SERV Division of Keith A. Tallia, Inc. STATE LICENSE No. 323417 CLASSIFICATION: A-HAZ., C61111140 STATE ENVIRONMENTAL ASSESSOR No. 01781 Telephone: (209) 754-1808 Fax: (209) 754-5726 Post Offlce Box 950 750 Industrial Way SAN ANDREAS, CAUFORNIA 95249 MONITORING sysTEM CERTIFICATION This form must be used to document testing and servicing of' monitoring equipment. It' 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 perforins 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: Norm's 76 Site Address: 633 E. Victor Rd. Facility Contact Person: Greg Wilson City Lodi Bldg. No.: Zip: 95240 Contact Phone No.: 2 0 9 )367-1795 Make/Model of Monitoring System: V e e d e r Root TLS 2 5 0 1 Date of Testing/Servicing: 6/4 /02 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: L—_�u n e r 10 In -Tank Gauging Probe. Model: 7 8 4 2 9 0— 3 0 7 Tank: ID: T2—Plus (I In -Tank Gauging Probe. Model: 784290-307 R3 Annular Space or Vault Sensor. Model: R S D F Of Annular Space or Vault Sensor. Model: RSD F EI Piping Sump/Trench Sensor(s). Model: V R 7 9 4 3 0 0— 2 0 5 (3 Piping Sump/Trench Sensor(s). Model: V R 7 9 4 3 0 0— 2 0 5 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: RI Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. Modcl:RJFX 1 V 13 Mechanical Line Leak Detector. Model: RJFX I V Tank Overfill /High -Level Sensor. Model: Model:61 S O P D r o p T U b e ❑ Electronic Line Leak Detector. 3 Tank Overfill / High -Level Sensor. Model: Model: 6_1S O D r o p Tu be Cl Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model X3 Shear Valve(s). (3 Shear Valve(s). _ §I Dispenser Containment Float(s) and Chain(s). Q Dispenser Containment Float(s) and Chain(s). ❑ OtheLrI(signeiipment type and model in Section E on Page 2). ❑ Other (s ecif a ui ment type and model in Section E on Paee 2). " Tank ID: T 3 =x R e g. Tank ID: P In -Tank Gauging Probe. M Annular Space or Vault Sensor. Model:784290-307 Model:RSDF__ ❑ In -Tank Gauging Probe. Model: V Piping Sump/Trench Sensor(s). r�lodcl:VR794300-205 O Annular Space or Vault Sensor. ❑ Piping SwnpiTrench Sensor(s). Model: _ Model: ❑ Fill Sump Sensor(s). _ Model:___ C3Fill Sump Sensor(s). Model: X] aNlechanical Line Leak Detector. Model:RTFX1 — ❑ Mechanical Line Leak Detector. _ Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model- X1 Tank Overfill / High -Level Sensor. Model:61 . D r o n Tu h e ❑ Tank Overfill / High -Level Sensor. Model: Dispenser Containment Sensor(s) a Xl Shear Valve(s). Model: H ❑ Dispenser Containment Sensor(s). Model P Dispenser Containment Float(s) and Chain(s). U Shcar Valve(s). Cl Dispenser Containment Float(s) and Chain(s). ❑ Other (s ecif a ui mcnt tv re and model in Section E on Paee 2). ❑ Other (s pecifv c ui ment type and model in Section E on Page 2). C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance tvitlr the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklis(s) necessary to verify that this information is correct and a Site Plan shONViKI, the layout of monitoring equipment. For :utv equipment capable of generating, such 1 ebur ts. I have .11so a11:101ed a cnl)N of the (r/r, rk all that applrJ: LI Syst,:na :et up report: U Alarm history report. lectutician Name (print): James P. Hesketh Cert./I.ic. No. 6-0669 Signatur - - -- - �Tel"11119 Companv Nan,r. Oil Equipment Service Plur- n,No 2e:)754-18 8 C 1 11 11 i