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MONITORING SYSTEM CERTIFICATION ^'Aftor Use By All Jurisdictions Within the State of Cali Authority Cited. Chapter 6. ealth and Safety Code, Chapter 16, Division 3 Title alifomia Code of Regulations 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 form tote local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: KISHIDA TRUCKING Site Address: 1725 ACKERMAN DR Facility Contact Person: MANAGER Make/Model of Monitoring System: B. Inventory of Equipment Tested/Certified City: LODI Contact Phone No:368-0603 Date of Testing/Service: 02/22/2002 Work Order Number: 2220938 Check the appropriate boxes to indicate specific equipment inspected/serviced CA Zip: 95240 Tank ID: 1 BLEND Tank ID: 71 In -Tank Gauging Probe. Model: OMNITECH in -Tank Gauging Probe. Model: 71 Annular Space or Vault Sensor. Model: FUEL ONLY Annular Space or Vault Sensor. Model: 71 Piping Sump/Trench Sensor(s). Model: FUEL ONLY Piping Sump/Trench Sensor(s). Model: Fill Sump Sensogs). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FX1 V/FX1 D Mechanical line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other (specify equipment type and model in Section E on page 2). Other (specify equipment type and model in Section E on page 2)_ an an In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other (specify equipment type and model in Section E on page 2). Other (specify equipment type and model in Section E on page 2). Dispenser Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: ® ShearValve(s). ShearValve(s) ® Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser Ispenser . E] Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ® ShearValve(s). ShearValve(s). 139 Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3 Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ®ShearValve(s). ShearValve(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). * If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. 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 any equipment capable of generating such reports, I have also attached a copy of the (Check all that apply): System set-up report; ❑ Alarm history report n PRINTED NAME:MATT HEMMINGSEN SIGNATURE:� 4-, COMPANY: Tanknology PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 03/01