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RECEIVED Appendix V1 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http:Pvvvvvv,� tf40P6RW-NTA L HEALTH MONITORING SYSTEM CERTIFICATION DEPARTMENT For Use By All 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 tank system ownerfoperator. The owner/operator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. A. General Information Mid City Ca FO Regen Bldg.No.: KINGCA Facility Name: Site Address: 13850 Devries Road,Lodi,CA 95242 Facility Contact Person: Jonathan Pakele Contact Phone No.: (916)439-6042 Make/Model of Monitoring System: PnuemercatorTMS2000 Date of Testing/Servicing:8/30/2017 B. Inventory of Equipment Tested/Certified Check the approEllate boxes to indicate specific Nuipment ins ctedlserviced: Tank ID: UST#3131 Diesel/550 gallons Tank ID: El In-Tank Gauging Probe. Model:'MP450 In-Tank Gauging Probe. Model:-----.__........_..........._...._._.._...... C1 Annular Space or Vault Sensor. Model: U§-(M ❑Annular Space or Vault Sensor. Model: El Piping Sump/Trench Sensor(s). Model: LS-600 Piping Sump I Trench Sensor(s). Model: []Fill Sump Sensor(s). Model: ........ ❑ Fill Sump Sensor(s). Model: .................. 0 Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model:__, Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Mechanical El Tank Overfill/High-Level Sensor. Model: Other(seecify equiement type and model in Section E on Page 2). [1 Other(specify equipment type and model in Section E on P29e 2. TankID: TankID: ❑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: Q Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model:........................ ...............__................ F11 Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: .......... C1 Electronic Line Leak Detector. Model:............................................. 0 Electronic Line Leak Detector. Model:, C]Tank Overfill/High-Level Sensor. Model: []Tank Overfill I High-Level Sensor. Model: 0 Other(specify equipment type and model in Section E on Pa 2). Other(specify eui ment to and model in Section E on Paq 2). 2 e Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Floats)and Chaints). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). 0 Dispenser Containment Sensor(s). Model: 0 Shear Vatve(s) 0 Shear Valve(s). 0 Dispenser Containment Floats)and Chain(s). ❑ Dis2enser Containment Floats)and Chainis). Dispenser ID: Dispenser ID: 171 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: rl Shear Valve(s). ❑ Shear Valve(s). [] Disgenser Containment Float(s)and Chain(s Disgenser 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 Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): EjSystem set-up El Alarm history report Technician Name(print): Ruben Becerra Signature:.Ruben Becerra .................. ............................ .............. Certification No.: 10993 f 5302139 License.No.: 703190 Testing Company Name: SunWest Engineering Const.,Inc. Phone No.:888-588-8737 Testing Company Address: 4780 Cheyenne Way,Chino,CA 91710 Date of Test!ng/Servicing: 8/30/2017 Monitoring System Certification Pagel of 4 12107 QA/QC APPROVED 8/31/20179:26AMBrandon Bo 2/21/07