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120816-022 <br />Appendix VI <br />(Copies of MonftodN System Certification form and UST Monitorhi; Plot Plan available at.httg://www.waterboards.ca.gov.) <br />MONITORING SYSTEM CERTIFICATION <br />For Use By All Ju K*hfn ft State of Caftnia <br />Authority Cited. Chapter 6.7, Health and Safety ; Chapter 16, Division 3, Title 23, California Code of <br />Regulations <br />This form must be toed to docurnivit testing and servicing of monitoring equipment. A separate certification or report must be prepared for <br />each monitoring control parte by the technician who performs A copy of this form must be provided to the tank system <br />owner/operator. The owner/operator must shit a copy of this farm to the local agency regulating UST systems within 30 days of test date. <br />A. General information <br />Facility : Mid City Ca 1~"O j&egen ate. No.: <br />Site Add : 13850 Decries Road city: Lodi zip: 95242 <br />Facility Contact Perm: Jonathan Pakele Contact Phone No.: (-J 916439-6042 <br />makewodei of Monitoring System PNEUMERCATOR TMS 2000 Data of T ng: 9/11/12 <br />B. Inventory of Equipmerit Tested(CoMed <br />Check 1WWftF.. <br />a a»..a <br />Tank ID: DIESEL <br />Q Annular 4: ^ or <br />ad M610 <br />■ Annular a. ,:: or K Yi- <br />t.be <br />1B Piping Sump / Trench Sensor(s). <br />Model: LS -600 <br />a Piping Sump/ Trench Sensor(s). <br />Model: <br />a FIN Sump Sensw(s). <br />Model: <br />13 FBI Sump Sensor(s). <br />Model: <br />13 Mechanical Una Leak Detector. <br />Modef <br />Mechanical Detectoc <br />Model: <br />■. Electronic Una Leak Detector. <br />!a.a <br />t - Detector.Model: <br />Q Overfill a e Sensor. <br />t -b ; A i <br />a Tank Overfill#t m Sensor. <br />w <br />Model: <br />"Z �. equipment,.rt VR <br />Tarlk ID. <br />Thr* 10: <br />a In -Tank Gaging Probe. <br />Model: <br />0 In -Tank Gauging Probe. <br />Model: <br />a Annular Spare or Vault Sensm. <br />Model: <br />a Annular Spare or Vault Sensor. <br />Model: <br />a Piping Sump / Trench v ,r <br />Model:lf. <br />Model: <br />■ Fill Sump x, a <br />Model: <br />0.6 <br />Fill tlSensor(s).. <br />Model: <br />M9chanW Uns Leak Detector. <br />Model: <br />Detector.a <br />El Mechanical Line Losk <br />Electronic a Leak <br />.. ..., Delec:W. <br />mom: <br />13 Tank Overfill / h -Level Serw. <br />model: <br />13 Tank Oveffll Ngh-L" Sensor. <br />mom: <br />■. � a3.bi( d4g <br />■: • ! .. t <br />w ., <br />■ i � t �. <br />oval <br />R a F <br />Dispenm ID: <br />1l DispenserContainment .:. rsor(,) <br />"..tb>. <br />at 4 ..4». ,. .: # .: is ». .. �•.4 " <br />#q,» <br />13 Shear Valve(s). <br />a Dispensera <br />a t.. <br />.t the facility contains more tanks or dispensers, copy this form. Include Information for every tank and dispenser at the facility. <br />C. n - 1 cwft that the equipment in this document Inspected/serviced In accordance with the manufacturers' <br />guidelines. Attached to Oft CeMcstlon Is Information (nchecklists) necessary to veft that Oft Inrfonnation Is correct <br />and a Plot Plan showing the layout of monitoring scluipment. For any equipment cof sucth re ,1 ttac a <br />copy of the k slr t o ,rp a Alarm history y Sim by� en r o X81 <br />Technician Name (prim: Ruben Becerra si 11112012101910 <br />certification No.: 10993 License. No.: 703190 <br />Testing Company : SUNWEST ENGINEERING INC. No.:( 909 ) 594-8737 <br />Testing Company Address: 2766 Pomona bl Pomona CA 91768 Date of T n ing: 09 / 11 / 2012 <br />Monitaft System Certification Pop 1 of 4 12W <br />QA/QC APPROVED <br />9/28/20124:17 PMDrandon <br />1 2/21/07 <br />