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t 4 8 'OIL -EQUIPMENT SERVI?# Division of Keith A. T4114 Inc. STATE LICENSE No. 323417 CLASSIFICATION: A- Z., C61D40 STATE ENVIRONMENTAL ASSESSOR No. 01781 Telephone: (209) 754-1808 Fax: (209) 754-5726 Post Office Box 950 750 Industrial Way SAN ANDREAS, CAUFORNIA 95249 This form must be used to document testing and servicing of' monitoring eyuipment. 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 fonTl 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. hnstructions are printed on the back of this page. A. General Information Facility Name: Norm:} g 76 Bldg. No.: Site Address: 633 E. Victor Rd. City: Lodi _ Zip: _ 95206 _ _ _ _ Facility Contact Person: Dale Heinz — Contact Phone No.: ( 2 0 9 )_ 948-9412 Make/ModelofMonitoring System: Veeder Root TLS 250 B. Inventory of Equipment Tested/Certified L11ecK the appropriate boxes to maleate speciuc equipment Date of Testing/Servicing: 7/ 13/00 Tank ID: 1 – Premium Tank ID: 2 ® In -Tank Gauging Probe. Model: VR 7 8 4 2 9 0– 3 0 7 _ X❑ In -Tank Gauging Probe u S Model: VR 7 8 4 2 9 0— 3-0 7 0 Annular Space or Vault Sensor. Model:RSDF XO Annular Space or Vault Sensor. Model: S i! M Piping SumpfTrench Sensor(s). Model: S R S 7 9 4 3 0 0— 2 0 5 X❑ Piping Sump/Trench Sensor(s). Model: G R 7 9 4 3 () 0— 2 0 ri O Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model:R�e(jZacke_t_ _FX1 Mechanical Line Leak Detector. Model: �p�aa r,k�� o�rF�� V ❑ Electronic Line Leak Detector. Model ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: 6 1.5 0_Dr4pi+lilJeXCI Tank Overfill /High -Level Sensor. _ Model:1 e nn,-`..,m„i. . ❑ Dispenser Containment Sensor(s): Model: _ _ ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). M Shear Valve(s). §I Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). ❑ Other (specify equipment a and model in Section E on Pae 2). ❑ Other (sRecify equipment t e and model in Section E on Paee 2). Tank ID: 3 — Regular Tank ID: 10 In -Tank Gauging Probe. ModeI:VR78A a n = ❑ In -Tank Gauging Probe. Model: X) Annular Space or Vault Sensor. ModeIRS-D _ ❑ Annular Space or Vault Sensor. --- Model V Piping Sump/Trench Sensor(s). ModeLSRS7_9 4 3 0 _n5_ ❑ Piping SumpiTrench Sensor(s)- Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: V Mechanical Line Leak Detector. Model Red,71�kPt FX1 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Xl Tank Overfill / High -Level Sensor, Model:61 SQDY O.p'. Ub_e ❑ Tank Overfill / High -Level Sensor. _ Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model Shear Valve(s). U Shear valve(s), l Dispenser Containment Float(s) and Chain(s)- ❑ Dispenser Containment Float(s) and Chain(s)_ ❑ Other (s2ecify a ui ment type and model in Section E on Pave 2). ❑ Other (s ecifv equipment type and model in Section E on Paee 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 anv equipment capable of "eneratino such reports. 1 dace also auachcrd a cop). of the 6.11” 1, a// that apply): ❑ System set-up report, ❑ AI' rn history r aor ., hec}ulician Name (print) James P. HeSk2tI1Cert./Lie. No 06_6-9 _ Signature: Testing Company Name Oil Equipment Service_ ____ Phone No.: ( 20 754-1808 CI*,ttit