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Mar. 27. 2013 8: 32AM No. 6553 P. 2 4 , AppenVix vi MONITORING SYSTEM CERTIFICATION For Use By All Jurlsty/ottons Within the State of Califomla Authority Cited!Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23, California Code of Regulations This form must be used to document iesGng and servicing of monitoring equipment,A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of thle form must be provided to the tank system owher/operator. The owner/operator must submit a copy of this foml to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: COstoo#1091 . 6 2680 B".PIa.: Site Address- 2680 Reynolds Ranch . City:.Lodi CA, zip: 95240 Facility Contact Person: Manager Contact Phone No.:(_). MakelModel of Monitoring System: VEEDER ROOT TLS-350 _ Dale of Testing/Servicing:__3_j 7 1 2 0 t 3 S. Inventory of Equipment Tested/Certified Check the appropriate boxse to Indlicoll epecilloequipmena I nsi acted/serviced: Tank to: T-1 Unlcadcd 87(TK-1) 30,000 Gallons Tank ID: T-2 UNLEADED .97 (TIS-2) 30,000 Gsliona W In-Tank Gauging Probe. Model:ARakT 10 x In-Tank Gauging Probe. Model: 047390-110 X Annular Space or Vault Sensor. Model:704380-301 X Annular Space or .vault Sensor. Model: 794380-307 N Piping Sump l Trench Seneor(s). Model:8570.112 mag sensor IHydro.aae x Piping Sump/Trench Sensor(s). Model: e6r0-e12,ms semorrHyd(o40 X FII Sump Sensor(s). Model:794380-323 Wi!"f0404 9 Fill Sump Senscr(a). Model: 79A360 323 W/liydrtr 304 Mechanical Line Leak Detector, Model: LA Mechanical Line Leak Detector. Model:BtA X Electronic Line Leak Detector. Model: PLL01e404.001 x Electronic Line Leak Detector. Model,PLLD/8464.001 x Tank Overf li/Hfgh-Level Sensor, Model: 847390-T 10 x Tank Overfill/High-Level Sensor. Model: 047390-110 Other f3pecity a ul msnt a and model In Section E on Page 2), Other Ls22cU e ui ment[Me and model In Sseik►h_Eon Pa 2). Tank to: T-3 Premium 91 90,000 Gallons Tank iD: T-4 ADDITIVE 1.500 Gallons In-Tank Gauging Probe, Model:847390.110 x In-Tank Gauging Prole. Model:$46391-001 if Annular Space or Vault Sensor. Model: 794360-301 k Annular Space ar Vault Sensor. madei: 794564 305 it Piping Sump l Trench Sensor(s). Model: 9570-112MO SOnaornydro-304 x Piping Sump/Trench Serisor(a), Model: 794380 123/Hydro-304 X Fill Sump Sensor(s). Model: 794382:2 WMKdro-304 Fill Sump Sansor(s). Modal: 332117-001 Mechanical Line Leak Detector. Model: WA it Mechanical Line Leak Detector. Model: FE-Petro `— x Electronic Uns Leak Detector. Madel: PLLD/8484-001 Electronic Line Leak Detector. Model:11A k Tank Overfill/Hlgh-Level Sensor. Model: 547390-110 k Tank Overf ll I High-Level Sensor. Model: 846391.601 r8hear s d l a u! enl t e and model in Section E on P e 2). Olh r i e ul mem a and model in Section E on PaLo to: 1-2 Dispenser 10: 34 ser Containment Senaor(s). Model: 3W/Hv ra-304 x DiapenserContainmentSensor(s). M7 1;794360-323 W/Hvdrw304 VaW(s)• X Shear Valve(,). sercontalnmentFloat 6 and Chains. Die eneer Contalament Floats and Chatn s. ID: -6 Dlapenser 10:7-8 K Dispenser Containment Sensor(s). Model: 794380.323 W/Hydro-304 If Dispenser Containment Senspr(a). Model:Z443110-323 W/Hvdro-304 X Shear valve(s). x Shear Velve(a). cis s or G ai ht Floats and Chain(s). Dispenser Containment Floalw and Chains. Dispenser Ip: 9-10 Dlspenser ID: 11-12 X Dispenser Conialnmant Senso4s). M0661: 794360-323 YwHydrn-304 If Dispenser Containment Sensor(s). Model: 799360-323 W/Hvdro-304 x Shear Valve(s). x Shear Valve(s). Dis enser Containment Floats and chains Dispenser Contatnmsnt t s and Chaln s. *II the facility contains more tanks or spensers,copy this farm. Include information for every tart and d1spenssr al the facility. C. Certification - I certify that the equipment Identified In this document was lnepectedlserviced In accordance with the manufacturers' guidelines. Attached to this Cortificallon is Information(e.g.manufacturers'checklists)necessary to verity that this Information Is correct and a Plot Plan showing the layout of monitoring equipmenL For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that trpptyp x System set-up x Alarm history report Edwin Coreas. Technician Name(print): Signature: Certification No.: B34020 License.No.: 804431 Testing Company Name:Jones Covey Grou ,Inc. Phone No.:(8ge,) 972-75$1 Testing Company address: 0585 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testinoorvicing:3/07! 2 0 1 3 Monitoring System Certilicallon Page of 19107