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�► M MON NG SYSTEM CETIFI TION 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 Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided t ereac ato The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of tRMEIVeD r. A. General Information Facility Name: 76-COUNTRYSIDE APR Bldg.No.: 11 Site Address: 14971 City: LODI M 4 Facility Contact Person: BICContact Phonc No.: 209 - � Make/Model of Monitoring System: VR TLS 350 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific a ui ment inspected/serviced: Tank ID: 87 Tank ID: 91 ®In-Tank Gauging Probe. Model: MAGA ®in-Tank Gauging Probe. Model: MAGA ®Annular Space or Vault Sensor. Model: 420 0 Annular Space or Vault Sensor. Model: 420 ®Piping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: ®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). Tank ID: DSL Tank ID: 10 In-Tank Gauging Probe. Model: MAG-1 ❑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: I ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: ❑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 ®Dispenser Containment Sensor(s). Model: 208 ® Shear valve(s). ®Dispenser Containment Sensor(s). Model: 208 ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). El Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑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 Plot 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 al/that apply): ❑System set-up ®Alarm history report Technician Name(print): HEATH MCEVER Signature: Certification No.: A27562 License.No.: 5236756-UT Testing Company Name: SST-SERVICE STATION TESTING Phone No.:(209) 465-5577 Testing Company Address: PO BOX 31465 STOCKTON CA 95213 Date of Testing/Servicing: 5/17/2010 Page 1 of 3 Rev(2/08)