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MONITORINGSYSTEM CERTIFICATION For' Use By All Jurisdictions Within theStale of California 4•rthgrity Cited: Chapter 6.7, Healthand Safety Code; Chaptel• 16, Division 3, Title 23, California Cotte of Regulations This form must be used to document testing and servicing of monitoring equipment. A, Separate certification or Spoort mu4t he orenared for lab monitor n m contr i isanet 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 Narne: ECONO GAS Bldg. Na.: Site Address, 880 E VICTOR ROAD City: LODI Zip: _ Nacility Contact Person: SHAWN Contact Phone No.: 209-468-3433 Make/Model of Monitoring System; VEEDER ROOT TLS 350 Date of Testing/Sorvicing: 7-8.09 B. Inventory of Equipment Tested/Certified Tank ID: 87 ® In -Tank Gauging Probe, Model; 847390-107 _ 0 Annular Space or Vault Sensor. Modcl: 794390.303 - - ® Piping Sump / Trench Sensor(s), Model: 794380.208 ❑ Fill Sump Sensor(s), Model: ❑ Mechanical Line Leak Detector, Model; Electronic Line Leak Detector. Model: _ Tank Overfill / High -Level Sensor, Model: 81-30 - q Other (specify equipment type and model in Section E on page 2), Tank ID: DIESEL ® In -Tank Gauging Probe. Model: 847390.107 _ 0 Annular Space or Vault Sensor. Model: 794390-303 ® Piping Sump/ Trench Sensor(s), Model: 794380-208 0 Fill Sump Sensor($), Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector, Model: ID Tank Overflll / High -Level Sensor. Modal: 81-30 Other (specify::i.!`ment typo and model in Section E on Page 2). Dispenser ID: 112 a Dispenser Containment Setr$or(s), Model: 794311.208 0 Shear Valve(s). Ej Dispenser Containment Float(s) and Chain(s), 99Dispenser ID: 6/6 ICL Dispenser OOntainrneni Sensor(s), Model: 794380-208 Shear Valve(s), Dispenser Containment Float(s) and Chain(s), Dispenser ID: 9/10 ® Dispenser Containment Sensor(s), Model: 794380-208 0 Shear Valve(s).---------- LE-1 Containment Floags) and Chain(a), *If the facility contains m t Tank ID: 91 ® In -Tank Gauging Probe, Model: 141390-107 0 Annular Space or Vault Sensor, Model: 794390.303_ 19 Piping Sump / Trench Sensor(s). Model: 794380.208 L] Fill Sump Sensor(s), Model; ❑ Mechanical Line Leak Detector, Model; 0 Electronic Line leak Detector. Model: ® Tank Overfill/ High -Level Sensor. Model: 8140 ❑ Other (spec* equipment type and model in Section Eon Page 2). Tank ID: ❑ In -Tank Gauging probe, Model: Annular SPace Or Vault Sensor, Model; Piping Sump / Trench Sciisor(s), Model; Fill Sump Sensor(s), Model; 0 Mechanical Linc Leak Detector, Mudd: Electronic Line Leak Detector. Model; Il Tank Overfill / High -Level Sensor, Model: Ll Other (specify equipment typo and model in Seotlon E on Page 2), Dispenser ID; 314 0 Dispenser Containment Sensor(s). Model' 794310-208 Shear Valvc(s), L:I Dispemscr Containment Float(s) and Chain(s), Dispenser ID; 718 Dispenser Containment Sensor(s). Model: 704380.208 Shear Valve(s), ❑ Disponser Containment Fluat(s) and Chain(s). Dispenser JD - El Dispenser Containment Sensor(s), Model; Shear Valve($). [] Dispensor Containment Float(s) and Chain(s), arc auks or dispensers, copy this form. Inclgde infortnaticn for every tank and dispenser at the facility, C. Certification - I certify that the equipment identified in this document was inapeetod/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 arm history report Technician Name (print): JAMES WILI_IAMS C r�ti(�catian No ' A32494 Signa Testing Company Name; S. Z. Service Station Maintenance i`cnse, No.: 433159 80 Site Address: 630 Houston Street West Sacramento, CA 95591 phone Na: 916 /Servs ing Date of Testing/Servici:ng; Page 1 of 3 UN -036 —1/4 www.un(docs.org Rev. 01/26MK z0oz XQI VIS HDIAHEIS ZS 08CZ TLC 9T6 XHd 80:OT OTOZ/80/TO