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FEB -20-2009 18:32 Service Station Systems 408 938 8888 P.03 Mon it st tOertificado For Use By A11 Jurisdiction? 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. Aseparate-certification or report mast he for each monitoring��rstemco�Itrol_�anel by the technician who performs the work. A copy of this foram must be 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: USAlresorro Bldg. No.: Site Address: 35 N. Cherokee Ln. Ia Elm St City: Lodi, CA Zip: 95240 Facility Contact Person: Manger Contact Phone No.: (209} 369-1525 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 1120/09 B. Inventory of Equipment Tested/Certified RJIU4CV�[41�11L' Q0 Tank ID- 01 u Model: VR 94739MOT D In - Tank Gauging Probe. Model: yR 847.107 % Annular Space or Vault Sensor. Model:.. VS -420_ _ _- S Piping Sump \ Trench Sensor (s). Model: VR 794380.208 D Fill Sump Sensor (s). Model: No— M Mechanical Line Leah Detector. Model Vam Sysm l.A2aoa ❑ Elecomic Line Leak Detector, Model: Naw Q Tank Overfill \ High -Level Sensor. Model: Naw 13 Other (specify equipment type and model in Section E on Page 2) 13 In - Tank Gauging Probe. Model: VR 94739MOT lS Annular Space or Vault Sensor. Model: VR 794394120 Ig Piping Sump \ Trench Sensor (s). Model; VR 704380-M — p Fill Sump Sensor (s). Model: —I— — M Mcchhanica) Line Leak Detector. Model: yawftnumw D Electronic Line Leak Detector. Model: N— E3 Tank Overfill \ High-Lovel Sensor, Model: No" D Other ( specify equipment type and model in Section E on Nage 2). Dispenser ID- 01.02 ❑ Dispenser Containment Sensor (s). Model: N— IX Sheat Valve (s). 11 Dispenser Containment Float (s) and Chain (s). Dispenser ID: D Dispenser Containment Sensor (s). Model: Nm - 13 Shear Valve W. IN Dispenser Containment Float (s) and Chain (s). Disp�enser JR: [3 i5ispenser Containment Sensor (s). Model: D Shear Valve (s). D Dispenser Containment Float (s) and Chain (s). Tank ID- 02 -Plus D In - Tank Gauging Probe. MWcl: VR 8473IN407 13 Annular Space or Vault Sensor. Model:VR 79 M -M M Piping Sump \ Tranch Sensor (s). Model: vR tsasw D Fill Sump Sensor (s). Model: None IX Mechanical Line Lcak Detector. Model:yar,orsymn t.to ❑ Electronic Linc Leak Detector, Model: No„■ q Tank Overfill \ High -Level Sensor. Model: N— p Other ( specify equipment type and model in Section E on Page 2). Tank ID• q in - Tank Gauging Probe. Model: D Annular Space or Vault Sensor. Model: 0 Piping Sump \ Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: p Mechanical Line Leak Detector, Model: D Electronic Line Leak Detector. Model: D Tarek Overfill \ High-level Sensor, Model: D Other ( specify equipment type and model in Section E on Page 2), Dispenser ID. 03-04 D Dispenser Containment Sensor (s). Model: Naw Gg Shear Valve (s). J1 Dispenser Containment Float (s) and Chain (s). Dispenser ID: 07-M D Dispenser Containment Sensor (s). Model: N- 13 Shear Valve (s). 11 Dispenser Containment floe (s) and Chain (s). Dispenser TD- D Dispenser Containment Sensor (s). Model: D Shur Valve (s). D Dispenser Containment Float (s) and Chain (s). •If the &cility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the Wlity C. Certification - I certify that the equipment Identified in this document was inspeeted/serwieed in accordance with the manufacturer's galdelines. Attached to this Certification is Information (e.g. manufacture' checklists) necessary to verify that this information Is correct and a Plot Plan showing the layout of monitoring equipment For any equipment capable of generating such reports, r have also attached a copy of the; (check all Oat apply), D System set-up ❑ Alarm history report Technician Name (print): Randy Wilkerson Signature: Mfg. Cert.##.: A32404 ICC# 5258560 -UT License. No.: 485184 Testing Company Name: Sere. Sta. Sys. Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose GA 95112 Date of Testing/Servicing: 1/20/09