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11/30/2009 16:30 FAX 2093683234 GEORGE KISHIDA INC Ap endix VI MONITORING SY�TEM CERTIFICATION For Use By All s Jurisdictio Within the State of Califomia Authority Cited: Chapter 6.7, Health and Safety Code; Cha6ter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipme�fL A separate certificatlon or repon must be prepared for each monitoring system control panel by the technician who performs the work, copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the locallgoney regulating UST systems within 3o days of test date, A. General information Facility N,,. KISHIDA TRUCKING Bldg. No.; Site ArtePrmaF 1726 ACKERMAN DRIVE City; LODI gip; e.,.,n�... n...__. - "Y v Pgrsnn KELLIE Make/Model of Monitoring System: OMNTEC OEL 8000 5. Inventory of Equipment Tested/Certified t �a 0 In -Tank Gauging Probe, -Model! MAG ® Annular Space or Vault Sensor, Model: ILS ® Piping Sump / Trench Sensor(s), Model: ULS ❑ Fill Sump Sensor(s). Model; 0 Mechanical Line Leak Detector, Model: FX1V ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor, Model: ❑ Other (specify equipment type and model in Section E on Page 2), Tank 10: Model: ❑ In -Tank Gauging Probe. Modes ❑ Annular Space or Vault Sensor. Model; ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: _ ❑ Tank Overfill / High -Laval Sensor, Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: NORTH DIESEL, Sensor(&), Cl Dispenser Containment Sensor(s). Model; ® Shear Valve(s). ® Dispenser Containment Float(S) and Chain(s), Dispenser ID: SOUTH DIESEL SATELITE ® Dispenser Containment Sensor($). Model: ® Shear Valve(&). ® 01spenser Containment Flost(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s), Model: ❑ Shear Valve($). ❑ Dispenser Containment Float(s) and Chain(s), the facility contains more tanks or dispensers, copy C. Certification - I Certify that the equipment Identified In this document was In guidelines, Attached to this Certification Is information (e.g. manufacturers' and a Plot Plan showing the layout of monitoring equipment. For any equipr copy of the report; (check at/ drat app(v): ❑ System set-up ❑ A Technician Name (print): FELIX RAMIREZ Certification No,: 834976 Testing Company Name: AFFORQA-TEST Testing Company Address: a19 2_"r_ST REET GALT. CA 9b632 Monitoring System CCrtification Contact Phone No.: M9) 3138.0603 Date of Tesung/Servicing: 1116/2009 Tank ID: DIE 13 In -Tank Gauging Probe, Model: ' M40- 0 Annular Space or vault Sensor. Model: iLS ® Piping Sump / Trench Sensor(s). Model: ULS ❑ Fill Sump Sensor(s). Model: Model: ® Mechanical Line Leak Detector, Model: FX1V ❑ Electronic Line Leak Detector. Model: ❑ Dispenser Containment Sensor(s), ❑ Tank Overfill / High -Level Sensor, Model: ❑ Other (specify equipment type and model in Section E on Page 2) fli "P ❑ In -Tank Gauging Probe, Model; ❑ Annular Space or Vault Sensor. Model; ❑ Piping Sump / Trench Sensor(s). Modes; ❑ Fill Sump Sensor(s). Model: 0 Mechanical Une Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model In Section E on Page 2). Dispenser ID: SOUTH DIESEL ❑ Dispenser Containment Sensor(s), Model: ® Shear valve(s). ® Dispenser Containment Ftoat(s) and Chain(s), Dispenser ID: ❑ Dispenser Containment Sensor(s), Model: ® Shear Valve(s)-, ❑ Dispenser Containment Float(s) and Chaln(s), Dispenser ID: Q Dispenser Containment Sensor(&), Model; ® Shear Valve(s). Dispenser Containment Floats) and Chain(s) every tank and dispenser at the facility. Page 1 of 4 Aced In accordance with the manufacturers' necessary to verify that this Information is correct a Of generating such reports, I have also attached a ' report Iture: 1- i $0 NO: 52273934-U1 06-1740 OTTL e No, _(269) 744.0113 of Testing/Servicing: 11.o@.09 2/21/07