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FEB -17-2011 16:23 Service Station Systems 408 938 8888 P.03 Monitoring System 'Equipment Certification For five By All Jurisdirdons Within The State of California Authority Cited. Chapter 6.7. Health and Safety Code, Chapter 16, Division 3, Title 23, Cal forWa Code of ftulatiomv This form must be used to document testing and servicing of monitoring equipment. A separate certification or report.MUS_h prep d & gagh mgnitoring system control panel by the technician who performs the work. A copy of this fort. must he provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST system within 30 days of test date. A. General information Facility Name: Shelirresoro Site Address: 35 N. Cherokee Ln. Bldg. No.: City: Lodi, CA Zip: 95240 Fatuity Contact Person: Manager Contact Phone No.: (209) 369-1525 Make/Model of Monitoring System: Gil EMG Date of Testing/Servicing, 1120/11 B. Inventory of Equipment 'rested/Certified Check the noaroorlate boxes to indicate specific equipment inspected/serviced: Tank M: 01-Rogu Tank Int 02 -Plus ❑ In - Tank Gauging Probe, Model: VR "73RR--107 O In - Tank Gauging Probe. Model: VR 947390.107 N Annular Space or Vault Sensor. Model: VR rW$0420 a Annular Space or Vault Sensor. Model: VR x04390 -ago 8 Piping Smug \ Trench Sensor (s). Model: VR 704384.208 a Piping Sump \ Trench Sensor (s). Model: VR 714380.208 ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: a Mechanical Litre Leak Detector. Model: RJ 11$458.8 ® Mechanical Line Leak Detector. Model• Vapariaw LD2000 ❑ Electronic Line L4uk Detector. Mndcl: Q Electronic Linc Leak Detector. Model; C3 Tank Overfill \ High•Level Sensor. Model: ❑ Tank Overfill \ High -Level Sister. Model: ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ other ( q—* equipment type and model in Section E on Page 2). Tank ID! 08 -Prom Tank ITS; ❑ In -Tank Gauging Frolte, Model: VR 847360-107 ❑ in -'rank Gauging Probe. Model: a Annular Space or Vault Sensor. Model: VR x14380.420 [] Annular Spice or Vault Sensor. Model: a Piping Sump \ Trench Sensor (s). Model: VR 704380-209 ❑ Piping Sump \ Trench Sensor (i). Model: a Fill Sump Sensor (a). Model: ❑ Fill Sump Senor (s). Model: Z Mechanical Line Leek Detect«r, Model: Vapartoaa LD2000 ❑ Medlanicni Linc Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ high -bevel Sensor. Model; ❑ 'yank Overfill \ High -Level Senor, Model: ❑ Other ( specify equipment type and model is Section E on Page 2). Other ( specify equipment type and model in Section E on Page 2), Dispenser 111- 07"02 Disppenser I • 03-04 _ -- ❑ D4enser Containment Sensor (s). Model: C]' ispe user Containment Sensor (s), Model: ® Shear Valve (s). a Shear Valve (S), a Dispenser Containment Float (s) and Gain (s). a Dispenser Contsirunent Float (i) and Chain (s). Divenser : 85.06 Dispenser ID• 07-08 p Dispenser Containment Sensor (s), Model: ❑ Dispenser Containment Sensor (i), Model: 181 Shear Valve (s), Shear Valve (s), M Dispenser Containment Float (s) and Chain (s). a Dispenser Containment Most (a) and Chant (s), Di enser ID' Dispenser ID: ❑ DispetSSer COtitalnntent Scmaor {s). Model: Q Dispenses Containment Sei= (s). Model: _ d Shear Valve (s). ❑ Shear valve (s). p Dispenser Containment Float (a) and gain (a). ❑ Dispenser Containment Float (s) and Chain W. *If the facility contains more tanks or dispensers, copy this form. Inclu& information for every tank and dispenser at the facility C. Certiftat't08 - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturer's guideltues. Attached to this Gertiticailon is information (e.g. manufactures' checklists ) necessary to verify that tilts information Is correct and a Pint pian showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the, ( chock all i tatapply). ❑ System set-up ❑ Alarm history report Technician Name (print): Bryan Lundie. Sigtlattac:'r�,�� Mfg. Cert.#.: B36094 ICC# 8001468 -UT License. No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 96112 Date of Testing/Servicing: 1/20111