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n 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 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 Facitty Name: MCI Kingdon Bldg. No.: Site Address: 13650 Devries Rd. City: Lodi zip: Facility Contact Person: Todd Hart is Contact Phone No.: 972-729.5671 Make/Model of Monitoring System: Pneumercalor TMS2000 Date of Testing/Service: 2/20/07 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment Inspected/serviced: Tank ID: Diesel ank ID: ✓❑ In Tank Guaging Probe. Model: 450 ❑ In Tank Guaging Probe. Model: ❑ Annular Space Sensor. Model: LS610 ❑ Annular Space Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ' L'S600 ❑ 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: ❑ Tank Overfill / High Level Sensor. Model: ❑ Tank Overfill / High Level Samar. Model: Other equipment type and model in Section E on Pa e 2). Other(specify anttype and model In Section E on Page 2). ank ID: ank ID: ❑ In Tank Guaging Probe. Model: ❑ In Tank Guaging Probe. Model: ❑ Annular Space Sensor. Model: ❑ Amular Space Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Stang 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: ❑ Tank Overfill / High Level Sensor. Model: ❑ Tank Overfill / High Level Sensor. Model: Other ispecify e ui ment type and model in Section E on P e 2). 0 other (specify ui ment type and model in Section E on Page 2). Dispenser ID: Dispenser to: ❑ Dispenser Containment Sensor. Model: ❑ Dispenser Containment Sensor. Model: ❑ Shear Valve(s). ❑ Shear Valve(s). Dimenser Containment Fioa s and Chain(s). Disoen=r Float(s) a Chain Dispenser ID: Dispenser lD: ❑ Dispenser Containment Sensor. Model: ❑ Dispenser containment Sensor. Model: ❑ Shear Valve(s). ❑ Shear Valve(s). Disgenser Containment Fioa Di riser Containment FI Chain(s). Dispenser ID: ispenserID: ❑ Dispenser Containment sensor. Model: ❑ Dispenser Containment Sensor. Model: ❑ Shear Valve(s). 10 shear Valve(s). Di§R=r Containment Float and al DiseCriser Contait=nt FI s and Chain *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 Inspectediserviced 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 monttoring equipment. For any equipment capable of generating such reports, i have also attached a copy of the report; (check ap that apply): F] system set-up ❑Alarm History Report Technician Name: Dennis Cardenas Certification No.: 10590 Testing Company Name: Balch Petroleum Site Address: 930 Ames Ave, Milpitas, CA Signature:,.-- Liscense No.: 396575 A / B/ C-10 / HAZ Phone No.: 408-942-8686 Date of Testing/Service: 2/20/07 Page 1 of 4