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9 0 RECEIVEL <br />MONITORING SYSTEM CERTIFICATION <br />for Ilse By All Jurisdictions Within the .94ae qf0d�fbnller FEB 2-0 2015 <br />Authorio, Cited, Chapter .6.7. Health rand Safe Chapter 16, Division 3. 7'jj,1(,23, California Code ofRegulevioi , <br />This tbrin must he used to docurnent testing and servicing of monitoring equipment. A <br />IENTAL <br />"4U <br />Sysigtn".li r Iiiiin , the work, A copy of form must be provided to the tank system ewmer!'opertuffll <br />, _ , U. -&I by the technician who performs IV ;�Mn"�060TIIPI:hrr <br />Wr:a 1 M06 C <br />trust submit a copy of this feint to the local agency regulating UST systems within 30 days of test date. <br />A. General Information <br />Facility Name: ARCO AMPM <br />. ........ ...... . County: !�,ANJOA�UIN. <br />Site Address: 880 E VICTOR RD <br />City: LODI ... . ...... <br />............... . ..... __ . . . ..... <br />Facility Contact Person: ARAN <br />Contact Phone 209,369-0958 <br />Make/Model of Monitoring SystemT1 S350 <br />Date of Testing./Servicine: 9123i20I4__ <br />H. Inventory of Equipment Tested/Certified <br />Tank ID: TI -87 <br />Tank ID: T2-91 <br />In -Tank Gauging Probe. Model: MAG <br />hi-Tard, (;ijueing Probe. Model: 4i !t; <br />Annular Space or Vault Sensor Model: 301 <br />Annular Space of VaUIC-ris'Or ',Jodcl. 301 <br />piping sump i'rrcrich scrisor(s), Model: 208 <br />Ninug sump j I renuh Smsorro Model, 208 <br />0 Fill Surrip Sensor(s). Model. <br />C3 Fill Sump Senson�) '14udcl <br />Mechanical Line Leak Det -101'. Model: 1-02000 <br />mechanical 1,inc t,cak lkrecror. 10odcl LD2000 <br />❑ Electronic Line leak Detector. Model <br />Fiectronic Line teak Detcctor- "Jodcl: <br />01'ank Overfill / I lilgh-Level Sensor. Model: <br />STank OverfilU fligh-Level Sensor. Model: Fl-%PPER <br />Other (specify equipment type and inodel in Section E oil Page 2). <br />[1 Other (specify equipment type and model in Section Fort Page 2), <br />Tank ID: T3 -DSL <br />Tank ID: <br />• In -Tank Gauging probe. Madel: MAG <br />n in- Fank 6auging Probe. ModcF <br />• Annular Space or Vaull Son or. Model: 420 <br />0 Annular `(pace or Vault Semor- Model: <br />• Piping Sump %"Trench Scrisor(s). Model: 208 <br />❑ Piping Sump /Trench Scnsor(s), Model: <br />• Fill surrip Sensorts). Model: <br />0 Fill Sump Sensor(s), Model: <br />0 Mcchankal Line Leak Detector. Model: LD2000 <br />[] mechanical i,inc Leak rxtector Model <br />El Electronic Line Leak, Detector. Model: <br />El Electronic, Line Leak detector. Nwel: <br />STank Overfill / High -Level Senior. Model: FLAPPER <br />Ej Tank Overfill I fligh-Level Scn.,,or. 'Model: <br />E3 Other (specify equipment type and inodel in onPag� <br />El Other (specify' Cguillment tape ype and inodel in Section F on Page 2). <br />Dispenser ID: to- <br />Dispenser ID:JLI4� <br />E3 Dispenser containtuent Sensons). Model, 208 <br />I)ispciiser Containment Scrisorco, klod,;J: 208 <br />®';hear Valvets), <br />rA Shear Valvc(s) <br />El Dispenser Contairinwril floats) and Chain(s). <br />C1 Dispenser Containment Floatts) and (Iiain(s). <br />Dispenser ID: ;516 <br />Dispenser 1W '7/8 <br />0 Dispenser Containment Sensons), Model: 208 <br />0 Dispenser Containment Sensor(s). kl(del 208 <br />Shear VaINT(s) <br />Shear Valvosi <br />Containin1c.rit 1`11,01,1adt(,,S) and Chain(s). <br />C] J)ispenser Containment i, katf and Ch, <br />Dispenser ID: 9/10 <br />Dispenser ID: <br />LEIN."penser <br />an <br />f)ispenscr('ontainiiientSciis(ir(s). Model: 208 <br />r(o t <br />01 )1'spriser 01AWDMent Seasor(,,), <br />'licar Valve(�). <br />S S "tflvt,) <br />EISticar valvo�o, <br />0 as ru'ra F a <br />Ej Dispenwr Containment Floatts) and Chain(s) <br />()isponser Containment Float(s) and Chait(s). <br />Check the appropriate boxes to indicate "cific equipment inspectcri/serviced: <br />C. Certification - I certify that the equipment identified <br />in this document was inspected/serviced in accordance with the <br />manufacturers' guidelines. Attached to this Certification is <br />information (e.g. manufacturers' checklists) necessary to verify that <br />this information is correct and a Plan showing the layout of monitoring equipment. For any equipment capable of generatin -uch <br />reports, I have also attached a copy of the report, (check all thar qj)ply): 0 System set-up Z Alarm history re <br />Technician Name (print): ALEXANDER TATE <br />Sip; azure: . .... . ........ <br />Certification B42662 <br />License No.: 433159 <br />................ <br />R Z Service Station aintenance Phone No,: (916) 371-238E1 <br />Site 1041 J`ri Date of Testing/Servicing: _ 9/23/2014 <br />... .... ... <br />Monitoring Certification Test Report.I ol'5 <br />