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MONIA&UNG SYSTEM CERTIFI TI o NEQ 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 4 djujflij.�is This form must be used to document testing and servicing of monitoring equipment.A separate certification wa &.rR4WUkjir each monitorine system control panel by the technician who performs the work. A copy of this form must V411W1djkbWUb16system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating LST systems within 30 days of test date. A. General Information Facility Name: ECONO GAS Bldg.No.: Site Address: 880 VICTOR ROAD City: LODI Zip: 95240 Facility Contact Person: MR SINGH Contact Phone No.: 209-369-0958 Make/Model of Monitoring System: VR TLS 350 Date of Testing/Servicing: 12-23-09 B. Inventory of Equipment Tested/Certified Check the appropriate.boxes to indicatespecific a ui ment inspected/serviced: Tank ID: 87 Tank ID: 91 Z In-Tank Gauging Probe. Model: MAGA Z In-Tank Gauging Probe. Model: MAGA Z Annular Space or Vault Sensor. Model: VR-303 ®Annular Space or Vault Sensor. Model: VR-303 Z Piping Sump/Trench Sensor(s). Model: VR-208 ®Piping Sump/Trench Sensor(s). Model: VR-208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: LD2000 ®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: Z In-Tank Gauging Probe. Model: MAG-1 ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: VR-303 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: VR-208 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: LD2000 ❑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 Z Dispenser Containment Sensor(s). Model: VR-208 Z Dispenser Containment Sensor(s). Model: VR-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: VR-208 Z Dispenser Containment Sensor(s). Model: VR-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: VR-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 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 re,port Technician Name(print): ED STEARNS Signature: �— Certification No.: A31048 License.No.: 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: /.2-2.3 C t Page 1 of 3 UN-036—1/4 www.unidoes.org Rev.01/26/06