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• • 130726-444 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httpJ/www.waterboards.ca.cI MONITORING SYSTEM CERTIFICATION For Use By Alt Judsolictions Within the State of Catifomia 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 owner/operator. 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 Bldg. No.: KINGCA Site address: 13850 Devries Road City: Lodi Zip: 95242 Facility Contact Person: Jonathan Pekele Contact Phone No.: 916-439-6042 Make/Model of Monitoring System: Pnumereator TMS 2000 Date of Testing/Servicing: 9/12/13 B. Inventory of Equipment Tested/Certified f1han4 thio anmmnrisMa hnvaa fn Inrtirata cnarlfte aniflrvnsnt insnPrtwd/ArvInAd! Tank ID: Backup Generator Tank Tank ID: 0 In -Tank Gauging Probe. Model: F In -Tank Gauging Probe. Model: MP -450 o Annular Space or Vault Sensor. Model: LS -610 0 Annular Space or Vault Sensor. Model: Q Piping Sump / Trench Sensor(s). Model: LS -600 0 Piping Sump / Trench Sensor(s). Model: a Fill Sump Sensor(s). Model: LS -600 D Fill Sump Sensor(s). Model: a Mechanical Line Leak Detector. Model: t] Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: s Tank Overfill / High -Level Sensor. Model: RA -200 p Tank Overfill / High -Level Sensor. Model: R Other (specify equipment type and model in Section E on Pace 2). O Other (specify equipment type and model in Section E on Pa 2). Tank ID: Tank ID: O In -Tank Gauging Probe. Model: G In -Tank Gauging Probe. Model: • Annular Space or Vault Sensor. Model: a Annular Space or Vault Sensor. Model: O Piping Sump / Trench Sensor(s). Model: O Piping Sump/ Trench Sensor(s). Model: O Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: [3 Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 13 Tank Overfill / High -Level Sensor. Model: O Tank Overfill / High -Level Sensor. Model: 0 Other (specify equipment a and model in Section E on Paos 21. 0 Other (specify eauioment type and model in Section E on Pa 2). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: G Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). O Shear Valve(s). O Dispenser Containment Floats and Chain(s). O Di2eenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: G Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: o Shear Valve(s). 0 Shear Valve(s). O Dispenser Containment Floats and Chain(s). O Dis enser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: CI Shear Valve(s). a Shear Valve(s). 0 Dispenser Containment Floats and Chains C9 Di enser Containment Floats and Chain(s). 'If the facility contains more tanks or dispensers, copy this torm. Inciucie mtormation for every ianK ano dispenser ai me tacmiy. 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 Pian showing the layout of monitoring equipment For any equipment capsbl of eneratin such repo. Ihave also attached a copy of the report; (check all that apply): C System set-up Alarm history reportnn�� qI�nyn� (�d�gbn�y pen�r K�$$�I (701, I Technician Name (print): Spencer Kissick Signature: 1a[u�J�.al:23 Certification No.: 8169987 License. No.: 703190 Testing Company Name: SunWest Engineering Constructors INC Phone No.:( 909 ) 594-9850 Testing Company Address: 2766 Pomona Blvd, Pomona CA 91784 Date of Testing/Servicing: 9/12/13 _ Monitoring System Certification Page 1 of 4 QA/QC APPROVED 9/13/20133:27 PMMike P. B 12107 2/21/07