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RECF ."VED Appendix Vi S E'D 2 17 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hltp://www.rvaterlsoards.ca.aov.) MONITORING SYSTEM CERTIFICATIOXNA RONM;LE-N-FHEALTH For Use By All Jurisdfcdons W1Wn ft State of Calllornin ��,� -�� Authority Cited:Chapter 6.7,Health and Safety Cade;Chapter 16,Division 3,Me 23, i Regulations This form must be used to dement 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 ownedoparator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 3D days of test date. A. General information Facility Name: Mid City Ca FO Ragen Bldg,No.:WNGCA Site Address: 13860 Dec Road,Lodi,CA 96242 Facility Contact Person:Jonathan Palo Contact Phone No.: (916)43948042 Make/Model of Monitoring System:ftonlrmtor TMS 2000 Date of Testing/Servicing:2016-09-01 13. Inventory of Equipment Tested/Cer6fied Check the swoorlate boxes to Indicate speclific sclulpawd Inst scliedilserviced: IF Tank ID. -Tank Gauging Probe. Magi:WP Oso In-Tank Gauging Probe. Model: nnular Space cr Vault Sensor. Model: La sto Annular Space or Vault Sensor. Model: ping Sump/Trer►ch Sensors). Model: e$moo Piping Sump/Trendn Serisor(s) Modal: ts Sump Sensors) Madel: FiA Bump Sensor(s). Model: echanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: ectronic Une Leak Model: Electronic Line Leak Detector. Madel: ank Ovefi11 a Kgh-Levet Sensor. Model: rRATank Overfill/High-Level Sensor. Model: ther u ent and model in Section E on Others ui ert and model in Section E on A 2. ID: Tank 1D:-Tank Gauging Prole. Model: in-Tank Gauging Probe. Modelnnular Space or Vault Sensor. Model: Annular Space or Vauft Seng. Model•ping Sump/Trench Sensor(s). Model: Piping Bump f Trend Senrsor(s). Model: BI Sump Sarwr(a). Model: Fill Sump Sensor(s). Model: Mechanical Una Leak Detector. Model:j I Mechanical Line Leak Detector. Model: Electronic We Leak Detector. Model: Electronic Una Leak Detector. Model: Tank Overfill/High-Level Sir. Model: Tank Overfill/High-Level Sir. Model; Other ispedfillument and model in Section E on Pic A Other fgga SpWggent=and modal In Section E on P 2). it serlD: 171spenser 10: Dispenser Contaimnen t Sensor(s). Madel: Dispenser Containment Sensogs). Model: Shear Valva(s). Shear Valve(s). D treat Containment Flows)and Chains Dispenser Containment Floats and Chain a. EltapenseriD MoIaLmnser ID: Dispenser Containment (a). Model: r est Sersorte). Model: Shear Valve(s). hear Valve(s). Dt Corrtadn4 s ment Floaand Chain(s). Containment Floats and Chains. Dispenser[D: olain 10: Disperser Containment Sansor(s). Model: 101 Dispenser Containment Sensor(s). Modal: Shear Vatve(s). Shear Valve(s). DJs' nser Containment Float(s) and Chains D� r Containment Moats and Cham . if the facility contains more tanks or dispensers,copy this form. Include irmatiorn for every tank and dispenser at the dirty. C. Cartit n - I certify that the equipment Identified In this document was InspectediserAced in accordance with the manufacturers' guidelines Attached to this Certification is Information(e.g.manufacturers'checklists)necessary to verity 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 aft dist apply): Mysum set-up ElAlarm history report id Smith Techrtdan Name(print): David Smith Signature:®av Cartification No.: 8 473 License.No.:703190 Testing Company Name: SunWest Engineering Const,Inc. Phone No.: 737 Testing Company Address.4760 Cheyenne Way,Chino,CA 91710 Date of TeshnglServicing:2016-09-01 Monitoring System Certification Paget of 4 12/07 QAIQC APPROVED 9111201612:31 PMBrandon B 1 2/21/07