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yu. =%AulYM1tIV 1 3CfiV14t STATE LICENSE No. 323417 44 Division O Keith A. T'al[, CLASSIFICATION: A -RAZ., C6ID40 f tai ST ENVASSESSOR No. 01781 Telephone: (209) 764-1 We Fax: (209) 764-6726 Post Office Box 960 760 Industrial Way SAN ANDREAS, CALIFORNIA 96249 This 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 forn 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 Site Address: 633 E. Victor Rd. Cit Lodi Bldg. No.: Zip: 95240 Facility Contact Person: Greg Wilson Contact Phone No.: ( 2 0 9 ) 3 6 7 —1 7 9 5 Make/ModelofMonitoring System: Veeder Root TLS250 B. Inventory of Equipment Tested/Certified Check the annrnnr:�ta M.,..— v . M— . Date of Testing/Servicing: 6 / 8 /01 Tank ID: Ti Super Tank ID: T2 Plus XI In -Tank Gauging Probe. Mode1:7 81 290-301. 0 In -Tank Gauging Probe. Modef7 81 290-301 jQ Annular Space or Vault Sensor. ModeIRSOF Qtl Annular Space or Vault Sensor. Model: RSDF X) Piping Sumprrrench Sensor(s). Model: 794100-205 0 Piping Sumprrrench Sensor(s). Model: 2.94 300- 0 U Fill Sump Sensor(s). )Q Mechanical Line Leak Detector. Model: Model: '( C3 Fill Sump Sensor(s). �_ Model: ❑ Electronic Line Leak Detector. R.T 1 6 - 0 5 6 Model Mechanical Line Leak Detector. ❑Electronic Line Leak Detector. Model: R.T 1 1 6=0 S- }Q Tank Overfill / High -Level vel Sensor. ❑ Dispenser Containment Sensors) _ Model: f I SDD -o-p +ube 0 Tank Overfill / High -Level Sensor. (�1odeI: _ Model: 5-1-S�DLO-P-Tuht'-- Shear Valve(s). Model: ---- --------- U Dispenser Containment Sensor(s). Model: _ )EI Dispenser Containment Floats d Chis t) anant). M Shear Valve(s). M Dispenser Containment Float(s) and Chain(s). ❑ Other (specify ui rent ty pc and model in Section E on Paac 2). ❑ Other (Specify a ui ment type and model in Section E on Pace 2). Tank ID: T3 Req. Tank ID: X3 in -Tank Gauging Probe. jf7 Annular Space or Vault Sensor. _ Model: -7-M 29 n-Q� _ Model LJ In -'Tank Gauging Probe. Model: )P Piping Sumprrrench Sensor(s). R$pF __ Model: 794300-295----_ ❑ Annular Space or Vault Sensor. J Piping Model: _ ❑ Fill Sump Sensor(s). Model: _ _ SumprTrench Sensor(s). ❑ Fill Sump Sensor(s). Model: Model: — X] Mechanical Line Leak Dctecto:. Model: RJ1 1 6-048 ❑ Mechanical Line Leak Detector. _- Model: ❑ Electronic Line Leak Detector. )i❑ Tank Overfill / High -Level Sensor. Model: _ Model: ❑ Electronic Line Leak Detector. -ill _ Model: ❑ Dispenser Containment Sensor(s) -610 -Qp-Tube . 1lodcl: U Tank Overt / High -Level Sensor. Model: -- - -- - -- Shear Valve(s). ----------- - U Dispenser Containment Sensor(s) Model - - - - ------ x❑ DispcnserContainmcnt Floai(s, and Chain(s) r U Shear Valve(s). U Dispcnsci Containment Floats) and Craik). ❑ Other (s ecif a ui rent tv )c and model in Section E on Paec 21 y U ()(her (specify equipment tv to and model in Section F on Paec 2). l C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' goidelinvs. :Attached to this Certification k information (e.g. manufacturers' checklists) necessary to verify that this infortnatiirn is correct and a Site flan showint, the lavout of monitoring equipment. For anv equipment capable of generatin;, Much rcport,�. 1 have also a ropy of the (rhe,-/, o// Char (1/r/,/r): ❑ System set up report: Alarm histol to )dirt. TecluticianName(print): James P. Hesketh Cell /I ac. No-: 6-0669_ Signature Testing Company Name Oil Equipment - Service ... _... _ _ Phony No.: ( 75'4-1808 i,,