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°�'�f�•`� L_ U MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California ROo' 2008 Authority Cited.- Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Calif ,t (( ode o Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitorii � %1� p A$ � ailed at the facility, a separate certification or report must be prepared for each monitoring system control panel by t tdttti rms 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. Instructions are printed on the back of this page. A. General Information Facility Name: Econo Gas Bldg. No.: Site Address: 880 E. Victor Road City: Lodi Zip: 95240 Facility Contact Person: Singh Contact Phone No.: (20 9) 369-0958 Make/Model of Monitoring System: Veeder Root TLS 350 _ Date of Testing/Servicing: 12/11/07 B. Inventory of Equipment Tested/Certified Check t e apEopriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 Tank ID: 91 X In -Tank Gauging Probe. Model: Mag -1 X In -Tank Gauging Probe. Model: Mag -1 X Annular Space or Vault Sensor. Model: 0794380-301 X Annular Space or Vault Sensor. Model: 0794380301 X Piping Sump / Trench Sensor(s). Model: 0794380-208 X Piping Sump / Trench Sensor(s). Model: 0794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: STP MLD X Mechanical Line Leak Detector. Model: LD 2000 ❑ 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: Tank ID: X In -Tank Gauging Probe. Model: Mag -1 ❑ In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 0794380-301 ❑ Annular Space or Vault Sensor. Model: X Piping Sump / Trench Sensor(s). Model: 0794380-208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: 616-056 ❑ 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 (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: 208 X Dispenser Containment Sensor(s), Model: 208 X Shear Valve(s). X Shear Valve(s). ❑ Dispenser Containment Ficat(s) and Chain(s). ❑ Dispenser Containment F'ioat(s) and Chnin(s). Dispenser ID: 5 & 6 Dispenser ID: 7 & 8 X Dispenser Containment Sensor(s). Model: 208 X Dispenser Containment Sensor(s). Model: 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: 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 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 verify that this information is correct and a Site 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- X larm history report Technician Name: Ed Stearns Signature: ---- Certification No. A31048 License No. 433159 Testing Company Name: BZ Service Station Maintenance Phone No.: ( 16) 371-2380 Site Address: 630 Houston Street West Sacramento, CA 95691 Date of Testing/Servicing: 12/11/07 Page 1 of 3