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02/09/2010 11:29 FAX 916 371 2380 BZ SERVICE STAT16N 0002 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, TIN,23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system Wntrol panel is installed at the facility,a separate certification or report gngt be=voted for each mailiit oring Ustoent cot JOA panel by the technician who perforins the work. A copy of this form must be provided to the tank:system owrtcr/oporator. The owner/operator must submit u 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. GeneralInformatiou Facility Name: Econo Gas Bldg, No.: Sitc Address: $80 E.Victor Road City: Lodi Zip: 95240 Facility Contact Person: Singh Contact Phone No.: (209)369-0958 _ MakelModel of Monitoring System:Veeder Root TLS 330 Date of Testing/Servicing: 12/11/07 B, Inventory of Equipment Tested/Certified Check the appropriate boxes to tttdleeto specific equipment fns ted/eorviced: Tank ID: 87 'tank ID: 91 X In-Tank Gauging Probe. Model: Mag-1 X In-Tank Gauging Probe. Modal; ft-1 X Annular Space or Vault Seng. Modal: 0794Si10.301 X Annular Space or Vault Samor, Model: 0794300401 X Piping Sump/Trench Scatsor(al Model; 0794380-208 X Piping Sump/Trench Serace(s). Model: 0784380-208 ❑Fill Stamp Sensor(s). Model: ❑Fill Sump Som or(s), Model: X Mechanical Line Leak Detector. Model: STP MLD X Mouhaniaat Linc Leak Detector. Model LD 2000 ❑F.lecuronia Lim Leak Detector. Modal: ❑kleotronio Line Leak Detector, Model: ❑Tank Gill/High-Level Smear. Modal; ❑'Tank Over6li/High-Lova!Senna. Model: ❑Other(speoigy equipment type and model in Section E on Pago 2). ❑Other(specify equipment typo and model in Section E on Page 21 Tank ID. Tank ID: X In-Tank Gauging Probe. Model; Mag-1 ❑In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 0794300.301 ❑Annular Spam or Vault Sensor. Model: X Piping Sump/Tronah Sensor(s). Mme: 0794390-208 ❑Piping Sump/Trench Senso(e). Model: ❑Fill Sump Sotim(s), Model: ❑Fill Sump Scrsor(a). Model: X Mechanical Line Leek Detector: Model; 616-068 ❑Mechanical Line Leak Detector. Model; ❑Electronic Line Lcolt Detector. Model: ❑Electronic Tine Lack Dokotor. Model: ❑Tank Overfill/High-Love!Sensor. Modal: ❑Tank Overfill/High-Level Smiar. Modal: ❑Other(specify ocpaigm+ent typo and model in Section ran Pago 2). [3 Other(apawiry equipment type and model in Section E on Page 2} Dispenser ID: 1&2 Dispenser ID: 3&4 X Dispenser Containment Son$or(a). Model: 208 X Dispenser Co ntaimnant Senso(s} Model: 208 X Shear Valve($), X Slum Valve($), ❑Disperser Containment Float(e)and Chain(s). ❑Dispenser Containment Fioat(s)and Chain(a). Dispenser ID: 6&6 Dispenser ID: 7&8 X Dispenser Containment Smsox($), Model 208 X Dispenser Containment Sensor(®). Model; 208 X Shear Velve(s). X Shear Valve(s). ❑Digm nsw Containment Float(a)and Chain(a). ❑Dispenser Containment Floats)and Chain(sl Dispenser ID: 9 a 10 Dispenser ID: X Dispenser Containment Sensor(s). Model: 208 ❑Dispmnew Containment Sesor(s} Model: X Slicer Valva(a}, ❑Shear Valvowt ❑Dispenser Containment Float(a)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 faoility. C. Certification - t 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 On X rm history rei)ort Technician Name: Ed Stearns Signature: Certification No, A31048 License No. 433159 Testing Company Namc: BZ Service Station Maintenance Phone Nu.:(916) 371.2380 Site Addrmss: 630 Houston Street West Sacramento, CA 95691 Date of Tcsting/Serv:icing: 12/11/07 Page 1 of 3 UN-036—1/4 wwwu nidecs.aq Rev.01/26/06