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' MONIARING SYSTEM CTIFI • TION For Use By All Jurisdictions Within the State of CRlifornia .fut6oriry Cited. Chapter 6.7,1�1ea11h and Safety Code; Chapter 16,Division 3, TFtle 23, California Code of Regulations This form most be used to document testing and servicing of monitoring equipment.A UgUAtg certification or report must be prepared for each monitoring system centrol panel by the technician who performs the work. A copy of this form most 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: ECONO GAS Bldg.No.: Site Address' 880 E VICTOR ROAD City: LODI Zip: Facility Contact Person: SHAWN Contact Phonc No.: 209-468-3433 Make/1vlodcl of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 7-8-09 B. Inventory of Equipment Tested/Certiffed Check the appropriate boxes to indicate specific a ui ment inspecteWservicet I Tank ID: 87 Tank ID: 91 ®In-Tank Gauging Probe. Model: 847390-107 ®In Tank Gauging Probe. Model: 847390-107 Annular Space or Vault Sensor, Model: 794390.303 ®Annular Space or Vault Sensor, Model: 7943908303 ®Piping Sump/Trench Scnsor(s). Model: 80.208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Fill Sump Set(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: 61-30 ®Tank Overfill/High-Level Sensor. Model: 61-80 ❑Otho(specify equipment type and model in Section 2 on Page 2). ❑Other(specify equipment type and model in Section 6 on Page 2). Tank ID: DIESEL Tank M., In-'yank Gauging Probe. Model: 847390.107 ❑In-Tank Gauging Probe, Model: ®Annular Space or Vault Sensor. Model: 794390.303 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Piping Sump/Trench Sensor(s). Madel: ❑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: 81.80 ❑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; 1/2 Dispenser ID: 3/4 ®Dispenser Containment Senwr(s). Model: 794380.206 ®Dispenser Containment SensoKs), Model: 794380.208 M Shear Valve(s). ®Shear Vulve(s). ❑Dispenser Containment Float(s)and Cltain(s). ❑Dispenser Containment Float(s)and Chain(s), Dispenser ID: 5/6 Dispenser ID: 718 I@ Dispenser Containment Sensor(s). Model: 794380-208 Dispenser Containment Sensor(s). Model: 794380-208 ®Shea Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chuin(s). ❑Dispenser Containment Ftoat(s)and Chain(s). Dispenser ID: 9/10 Dispenser ID: ®Dispenser Containment Sensor(s). Model: 794380.208 ❑Dispenser Containment Sensor(s). Model: Shear Valve(s). 0 Sherr Valve(s). ❑Dispenser Containment Fkt*s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). off the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Ce Cation-I certify that the equipment identified In this document was Inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certifieation 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 Cerlif cation No.: A32464 �etme.No.: 433159 Testing Company Name: B.Z. Service Station Maintenance Phone No.:(916) 3712380 Site Address: 630 Houston Street West Sacramento,CA 95691 Date of Testing/Servicing: Page 1 of 3 UN-036-1/4 www.unidoes.org Rev.01/26106 I Z0oz NOI, VIS SDIAHEIS ZS 09CZ TLC 9T6 YU TC:£T OTOZ/OT/ZO