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SEP 12 2010" Appendix 'Vi (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http:/?www.waterboards.ca.cfov.} MONITORING SYSTEM CERTIFICATION 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 ownertoperator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Mid City Ca FO Regen 131dg.No.: KINGCA Site Address: 13850 Devries Road,Lodi,CA 95242 Facility Contact Person: Jonathan Pakele Contact Phone No.: (916)439-6042 MakelModel of Monitoring System: Pnuemicator TMS 2000 Date of TestingJServicing:2016-09-02 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecffic a ui ment ins ected/serviced: Tank ID: UST 93131DieW1560gallon Tank ID: El In-Tank Gauging Probe. Model: MP-450 ❑ In-Tank Gauging Probe. Model: i]Annular Space or Vault Sensor. Model: Ls 610 ❑Annular Space or Vault Sensor. Model: F1 Piping Sump/Trench Sensor(s). Model: Ls 600 ❑ Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Q Tank Overfill J High-Level Sensor. Model: Mechanical RA 200 ❑Tank Overfill/High-Level Sensor. Model: Other(specify ui ent type and model in Section E on Pae 2). ❑Other(specifX e2uieTent tx2e and model in Section E on Pa a 2). TanklD; 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: ❑Piping Sump/Trench Sensor(s). Model: Q Fill Sump Sensor(s). Model: ❑FII Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: ❑Tank Overfill,!High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other(specify ui ent type and model in Section E on Pae 2). Other(specify a ui ment type and model in Section E on Pa e 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chains. Dispenser Containment Floats and Chains. Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floatjsj and Chains. Dispenser Containment Floats and Chains. DispenserfD: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis nser Containment Float(s)and Chain(s I[] Dis enser Containment Float(s)and Chain(s). 1f 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): ❑System set-up BAiarm history report Technician Name(print): David Smith Signature:David Smith - Certification No.: 8260473 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 Testing/Servicing:2016-09-02 Monitoring System Certification Page 1 of 4 12J07 QA/QC APPROVED 9/1/201612:31 PMBrandon B i 2/21/07