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Pit • k <br /> ,Appendix V1 <br /> M(NITORING SYSTEM CERTIFICATION <br /> il ar use Ely Ail Jurisdictions within the State Of California BAR 2 62 <br /> Authority Cited: chapter li Health ail� I Safety Code; Chapter 16, Division 3,TIde 23,Califon is Code of 010 <br /> Regulations, S svv ioi4;C2. <br /> This form miust be used to document testing and ser] cin rig of monitoring equipment.A se rale Certification Or f8pOrt MUSt De PrA plilfad for r7 11 <br /> each monitoring system Control panel by the techniij n who performs the work.A copy of this form must be provided to the tank,syslem <br /> ownerloperator.The ownefloperellor must subm A a py of this form to the local agency regulating UST systems%Mthln 30 days of test date. <br /> A. General Information <br /> Facility <br /> W-1 OASIS PLAZA VALERO#1_ <br /> site <br /> Arldro.q_%, Sao 9 CHEROKEE LANE City: LODI CA Zip: — <br /> Facility Contact <br /> Pe.rRnn MIKE Contact Phone Na-: (-209)36 1-0127 <br /> MBketMcdel of Monitoring System: Vii 'ROOT TI,$359 Date of Testni icing 2125/0110 <br /> 13. Inventory Of Equipment Tested/Certifig I <br /> Check thea ro riate boxes to Indicate s tlflc equipment t frispectediserviced; <br /> Tank ID- 87 OCT Unk ID: 91 OCT <br /> S In-Tank Gauging Probe. Model, l 0 In-Tank Gauging Probe, IV ode[: MAO 2 <br /> 13 Annular Space of Vault Sensor. Model: 420 i El Annular Space or Vault Sensor, IV odel: SPLIT W DSL <br /> * Piping$Limp I Trench Senaor(a). Model: 208 0 Piping sump i Trench Sensor(6). IV odel: 208 <br /> * Fill Sump Sensor(s). Model. —1 0 Fill Sump Sensor(s). IV odel: <br /> 19 Mechanical Line Leak Detector. Model: LD-;I Q 0 Mechanical Line Leak Detector. N odel: ILD-2000 <br /> CI Electronic Line Leak Detector. Model: Electronic Line Leak Detector. N odel: <br /> 0 Tank Overfill I High-Levet Sensor. Model: ❑ Tank Overfill/"Igh-Leviel Sensor. IV odel: <br /> 0 Other(specify equipment type and model in Sefton on Page 2) 0 Other(specify equipment type and modal in Section E on Page 2). <br /> Tank ID: IDSL Tank ID: <br /> 0 In-Tank Gouging Probe. Model: MAC,I (j In.Tan;(Gauging Probe. M 3de!: <br /> M Annular Space or Vault Sensor. Model: 420 1 [1 Annular Space or Vault Sensor, M3de[ <br /> 0 Piping Sump I Trench sensof(a). Model: 20-8 ...... ... 0 Piping Sump I Trench Sensor(s), M:1Del. <br /> 0 Fit I Sump Serlsor(s). Modei1 0 Fill Sump Sensof(s). M 3del: <br /> Z Mechanical Line Leak Detector. Model: Ii a D Mechanical Line Leak Detector. M:>del: <br /> 0 Zleclronic Line Leak Detector. Mod ei, M Electronic Line Leak Detwlor. M?del: <br /> 0 Tank Overfill I High-Level Senror, Model� Ej Tank Overfii t HIgh-Level Sensor. M:)del: <br /> 0 Other(specify equipment type and model in Section on Page 2). 0 Other(specify equipment type and made I in Section 15 on Page 2). <br /> Dispenser ID: 1-2 Dispenser ID: <br /> D Dispenser Containment Sensor(s) Model: YES M Dispenser Containment Sarisor(s), Madel: <br /> 0 ShcarVaive(s). El Shear Vaive(s). <br /> 0 Dispenser Containment Fli and C*li I 0 Dispenser Containment Float(S)Ond Chain(s). <br /> Dispenser ID; 34 Dispenser 10: <br /> Q Dispenser Containment Senso4s), Model: YES ED Dispenser Containment Sensor(5), M)del: <br /> 0 Shear Valve(s), El Shear Valve(s). <br /> 0 Dispenser Containment Float(r)and Chain(s). <br /> FI Dispenser Containment Floal(s)and Cha n(s) <br /> Dispenser ID: <br /> Dispenser ID; <br /> 0 Dispenser Containment <br /> El Dispenser Containment Sensor(s), Model, Senroii Modek <br /> 0 shear valvate), ❑Shear Valve(s), <br /> 0 Dispenser Containment Floats)and Chain(s), ❑Dispenser Containment Float(s)and Chaiii <br /> V The TAdlity Contains rriors tank%or dispensers,copytb '01m, Include irii for every tank and dispenser at the faculty. <br /> C.certification-I cerli that the equipment idontifie in this document was Inspected1serviced In accordance With the man,ifacturars' <br /> guidelines,Attached to thill,Certification Is Informal I(e.9,manufacturers'checklists)necessary to verify that this Information li Correct <br /> arid a Plot Plan snowing the layout of moriltorltig eq 3ment.For any equipment capable of generating such reports,I have 0140 attached a <br /> copy of the report;(check off that apply) 08 tern set-up 0 Alarfn ftl5tory report <br /> Technician Name(print): DAVE WINKLER <br /> Signature: <br /> Certification No.: 5263373-UT License No: 08-1739 <br /> Tes'6ng Company Name: AFFORDA-TEST Phone No. (209)744-0113 <br /> Testing Company Address; 416.Z STREET GALT;r A 95832 D210 of Tegting/Serviclng, 2-25-.2010-- <br /> Monitoring System Certliftcatli I Page I of 4 2/21107 <br /> TO 39Vd sisvo/oinv i(io-1 iio 888169611 "15T :Yj OTOZ/9Z/EO <br />