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Ma r. 27. 2013 8:33AM No. 6553 P. 3 AppenOlx VC C?NITRiNG SYSTEM CERTIFICATION For Use ByAff Jurisdictions Within the State of California 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 testing 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 this form must be provided to the lank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems Wlhin 30 days of test date. A. General information Factlity.Narne; Costco#1091 . Bldg.No..2880 Silo Address: 2680 Reynolds Ranch, City. Lodi CA, Zjp: 95240 Facility Contact Person: Manager Contact Phone No..{__) MakelModet of Monitoring System:VEEDER ROOT TLS-350 Dale of Tesfing/ServUrig:�� 2 D 1 3 B. Inventory of Equipment Tested/Certified Check the a2propriato boos to indicates ecWcul mr;rnt Ins (edlfserviceri: FAnnufar ADDITIVE VENT aox Tank to: GAS VENT BOX. Gauging Probe. Model: In-Tank Gauging Probe, Model: Space or Vauq Sensor. Model: Annular Space or Vault Sensor. Model: ump/Trench Sensor(s). Model:AoaiW�.77A9 323xrtar9-M Piping Sump t Trench Sensor(s). Modal:p Sensor(s). Model: Fill Sump Sensor(s). Model; ical Line Leak Detector. Modal: Mechanical Line Leak Detector. Model, lr Electronic Line Leak Detector, Model: Electronic Line Leak Detector. Model: x Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor, Model: Other(Specify e u men[Igo and modol—in E on Pane 2). Others cit a ui ant I e and mope[in Section E on P e z. Tank ID: Tank ID: NIA In-Tank Gauging Probe. Modal: in-Tank Gauging Probe. Model WA Annular Space or Vault Sensor. Model: Annular Space or Vaull Sensor. Model: NIA Piping Sump i Trench Sensoria), Model: Piping Sump/Trench Sensor(s). Model, NIA Fill Sump Sonsor(s). Model. _ Fill Sump Sonsor(s). Madel: WA Mechanical Line Leak Detector. Modal: Mechanical Line Leak Detector. Modal, NIA Electronic Line Leak Detector. Model_ Electronic tine Leak Detector. Model: NiA Tank Overfill 1 High-Level Sensor. Model: Tank Overfill/Hlgh-Level Sensor. Model: NIA Other wcl =m"t Igo and modol in Section E on Page 2. Other a ci a u( mens type and model in S bon E Page 2). Dispenser ID; 13-14 Dlapenser BD: 15-16 Dispenser Containment Sensor(6), Model:I843eo-323 w!Hvd� Dispenser Containment Sensor(s). Model: 923 wt Hvdro-3iM Shear Velve(s). Shear Valve(s). Dts anssr Containment Flost s and Chain(s). Dis neer ntalnmam Floats and Ghain s. Dispenser to: Dispenser ID; Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Vatve(s). Diap2nper Containment Float(s) and Chains. Dispenser Contathmsnt Floats and Chains. DlspenserID; Dlspenserla: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model; Shear Vaive(s). Shear Velvets). Dispenser Containment FloAjW and Ghat Dfagenlor Containment Floats and Chains. 'If the facility contains more tanks or dispensers,copy this form, include information for every tank and dispenser at the facility. C. Cerilflcadon.- I carilly that the equlpinint Identltted•In this document was Inspectediserviced In accordance with the manufacturers, guidelines. Attached to this Certification to informellon(e.g.manufacturers'cheokllsle)necessary to verity that this information Is correct end a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generahrmg such reports,i have also attached a copy of the report;(chock ell that appal: x System set-up d Alarm history report m G$eit. Technician Name(print): Edwin Coreas. Signature: Certification No.: B34020 License,No.: 804431 Testing Company Name: Jones Covey Group,Inc. Phone No.; 8S( 8 ) 872-7581 Testing Company Address: 9595 Lucas Ranch Rd.9100 Rancho Cucamonga CA 91730 Date of Testing/Servicing.3/47 i 2 0 1 3 Monitoring System Certification Page of 12107