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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 Facility Name: ECONO GAS Site Address: 880 VICTOR RD. Facility Contact Person: LUCKY Make/Model of Monitoring System: VEEDER ROOT TLS350 B. Inventory of Equipment Tested/Certified Check the aoorooriate boxes to indicate specific eauioment insnected/serviced Bldg. No.: City: LODI Zip: 95240 Contact Phone No.: 209-369-0958 Date of Testing/Servicing: 12/22108 Tank ID: 87 Tank ID: 91 X In -rank Gauging Probe. Model: MAG -1 X In -Tank Gauging Probe. Model: MAG -1 X Annular Space or Vault Sensor. Model: VR 301 X Annular Space or Vault Sensor, Model: VR 301 X Piping Sump / Trench Sensor(s). Model: VR 208 X Piping Sump / Trench Sensor(s). Model: VR 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: FE PETRO X Mechanical Line Leak Detector. Model: LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ 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). Tank ID: DSL Tank ID: X In -Tank Gauging Probe. Model: MAG -1 ❑ In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: VR 420 ❑ Annular Space or Vault Sensor. Model: X Piping Sump /'Trench Sensor(s). Model: VR 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: 116-058 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line beak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ "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 X Dispenser Containment Sensor(s). Model: VR 208 X Dispenser Containment Sensor(s). Model: VR 208 X Shear Valve(s). X 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 X Dispenser Containment Sensor(s). Model: VR 208 X Dispenser Containment Sensor(s). Model: VR 208 X Shear Valve(s). X Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9&10 Dispenser ID: X Dispenser Containment Sensor(s). Model: VR 208 ❑ Dispenser Containment Sensor(s). Model: X Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chanes). *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 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 X Alarm history por Technician Name (print): ED STEARNS Signature: C A31048 433159 Testing Company Name: B. Z. Service Station Maintenance Phone No.: (916) 371-2380 Site Address: 630 Houston Street West Sacramento, CA 95691 Date of Testing/Servicing: 12/22/08 Page 1 of 3 UN -036— 114 www.unidocsorg Rev.St/mo&