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RECEIVED Appendix VI AUG 2 0 2018 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htto://www.waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL For Use By All Jurisdictions Within the State of California HEALTH DEPARTMENT Authority Cited.Chapter 6.7,Health and Safety Code;Chapter 16, Division 3, Title 23, California Code o/ 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 Mid City Ca FO Regan KINGCA Facility Name: Bldg.No.: Site Address: 13850 Devrles Road,Lodi,CA 95242 Facility Contact Person: Jonathan Pakele Contact Phone No.: (916)439-6042 Make/Model of Monitoring System: Pnuemercator TMS 2000 Date of Testing/Servicing:8!712018 B. Inventory of Equipment Tested/Certified Check the appmpriate boxes to Indicatespecific equipment insl ectediseiviced: Tank ID: UST#313/Diesel/550 gallons Tank ID: 0 In-Tank Gauging Probe. Model: MP-450 ❑ In-Tank Gauging Probe. Model: .❑Annular Space or Vault Sensor. Model: LS-610 ❑Annular Space or Vault Sensor. Model* - El Piping Sump/Trench Sensor(s). Model: LS 600 ❑ Piping Sump/Trench Sensor(s). Model: EI FII 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: E)Tank Overfill/High-Level Sensor. Model: Machaniml/RA200Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment a and model in Section E on Pae 2). Others c' equipment and model in Section E on Page 2). Tank ID: Tank ID: ❑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: ❑FII 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: El Other(specify equipmenLtype and model in Section E on Pa 2. Other(s2ocity equipment and model in Section E on Pace 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensoria). Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chain(s). Dis enser Containment Floats and Chain(s). Dispenser 10: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Dispenser Containment Senson(s). Model: ❑ Shear Valve(s). ® Shear VaMe(s). Dispenser Containment Floats and Chain(s). Dis enser Containment Floats and Cherie). Dispenser lD: Dispenser 10: ❑ Dispenser Containment Sensoria). Model: ❑ Dispenser Containment Sensoria). Model: ❑ Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Floats and Chains Dis enser Containment Floats 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 verity that this Information is correct and a Plot Plan showing the layout of monitorin equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): Lj System set-up ❑Alarm history report Technician Nanta(print): Ruben Becerra Signature:Ruben Becerra ea.m1&W.0TW WAT-07W Certification No.: 10993/5302139 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 Testing/Servicing:8/7/2018 Monitoring System Certification Page 1 of 4 12/07 QA/QC APPROVED 8/7/20182:56 PMTeresa Ant 1 2/21/07