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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 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): X System set-up arm history report - Technician Name (print): JAMES WILLIAMS Signa Ctrt;tiraric,n Nn A32464 License. No.: 433159 Testing Company Name: B. Z. Service Station Maintenance Site Address: 630 Houston Street West Sacramento, CA 95691 Page 1 of 3 Phone No.: (916) 371-2380 Date of Testing/Servicing: UN -036 —1/4 www.unidocs.org Rev. 01/26/06 ONI RING SYSTEM CETIF TION 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 thisst be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulatst3�0 days of test ;,; date. A. General Information FacilityName: ECONO GAS JUL d�OV •• Site Address: 880 E VICTOR ROAD City: LODI EA Zip: Facility Contact Person: SHAWN Contact Phone Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testirigl��rvlC�i-8-09 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins cted/serviced: Tank ID: 87 Tank ID: 91 Z In-Tank Gauging Probe. Model: 847390-107 Z In-Tank Gauging Probe. Model: 847390-107 Z Annular Space or Vault Sensor. Model: 794390-303 Z Annular Space or Vauif Sensor. Model: 794390-303 Z Piping Sump / Trench Sensor(s). Model: 794380-208 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ 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: Z Tank Overfill / High-Level Sensor. Model: 61-SO Z Tank Overfill / High-Level Sensor. Model: 61-SO ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DIESEL Tank ID: Z In-Tank Gauging Probe. Model: 847390-107 ❑ In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794390-303 ❑ Annular Space or Vault Sensor. Model: Z Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detectcr. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High-Level Sensor. Model: 61-SO ❑ Tank Overfill / High-Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 112 Dispenser ID: 3/4 Z Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 Z Dispenser Containment Sensor(s). Model: 794380-208 Z Dispenser Containment Senso-(s). Model: 794380-208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9/10 Dispenser ID: Z Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the 5acility. 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 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): X System set-up arm history report - Technician Name (print): JAMES WILLIAMS Signa Ctrt;tiraric,n Nn A32464 License. No.: 433159 Testing Company Name: B. Z. Service Station Maintenance Site Address: 630 Houston Street West Sacramento, CA 95691 Page 1 of 3 Phone No.: (916) 371-2380 Date of Testing/Servicing: UN -036 —1/4 www.unidocs.org Rev. 01/26/06