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*RECEIVED MONITORING SYSTEM CERTIFICATION OCT 2 5 2016 For Use By AfiJurisdictions Within the State of California Authority Cited: Chapter 61, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code ENVIRON HEALTH This form must be used to document testing and servicing of monitoring equipment. A setogMification or report mustbe Drepar&d&F-cach~it@oFiM-r item control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operht6l—"?b1ivh&/W"Ar 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: ARCO County: SAN JOAQUIN Site Address: 880 E. VICTOR RD City: LODI Facility Contact Person: Contact Phone Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 9/22/2016 B. Inventory of Equipment Tested /Certified Tank I : 87 Tank ID: 91 ID In -Tank Gauging Probe. Model: MAG ED In -Tank Gauging Probe. Model: MAG 10 Annular Space or Vault Sensor. Model: 301 Z Annular Space or Vault Sensor. Model: 301 Piping Sump / Trench Sensor(s). Model: 208 R Piping Sump / Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: LD2000 9 Mechanical Line Leak Detector. Model: LD2000 El Electronic Line Leak Detector. Model: M Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: FLAPPER 0 Tank Overfill / High -Level Sensor. Model: FLAPPER [3 Other (specify equipment type and model in Section E on Page 2). [1 Other (specify equipment type and model in Section E on Page 2). Tank ID: DSL Tank ID: • In -Tank Gauging Probe. Model: MAG 0 In -Tank Gauging Probe. Model: • Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: • Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: LD2000 ❑ Mechanical Line Leak Detector. Model: [3 Electronic Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model: * Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Tank Overfill / High -Level Sensor. Model: * Other (specify equipment type and model in Section E on Page 2). C] Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 3/4 Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 208 Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser to: 7/8 • Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s), Model: 208 • Shear Valve(s). [D Shear Valve(s). El Dispenser Containment Float(s) and Chain(s). C] Dispenser Containment Float(s) and Chain(s). 0 EDispenser 1D.: 9/10 Dispenser ID: Dispenser r rC Dispenser Containment Sensor(s). Model: 208 E] Dispenser Containment Sensor(s). Model: 0 ; Valve(s). Shear Valve(s). Shear Valve(s). S 0 0 is use, C', Dispenser Containment Float(s) and Chain(s). C1 Dispenser Containment Float(s) and Chain(s). Check the appropriate boxes to indicate specific equipment inspected/serviced: 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): [I System set-up F1 Alarm history report Technician Name (print): TIM BURKART Signature: Certification B44849 License No.: 433159 Testing Company Name: B. Z. Service Station Maintenance Phone No.: (916) 371-2380 Site - 1041 Triangle Court West Sacramento, CA 95605 Date of Testing/Servicing: 9/22/2016 Monitoring Certification Test Report I of4