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MONITWUNG SYSTEM CERTIFIGWON se By All Jurisdictions Within the State of Califom Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3 Title 23, alitomia Code of Regulations This form must be used to document testing and servicing of monitoring equipment If more than one monitoring system control panel is installed at the facility,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 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 Name: USA 1165 City: LODI CA Zip:95242 Site Address: 2500 W.LODI AVE. Contact Phone No: 333-9834 @ LOWER SACRAMENTO RD. Date of Testing/Service: 09/29/2004 Facility Contact Person: MGR-SHARON Make/Model of Monitoring System:TLS-350 Work Order Number: 2232464 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 1-87 Tank ID: 2-89 71 In-Tank Gauging Probe. Model: MAG zi In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: LS3 Annular Space or Vault Sensor. Model: LS3 ( Piping Sump/Trench Sensor(s). Model: 208 Piping Sump?mnch Sensor(s). Model: 206 X Fill Sump Sensor(s). Model: 206 206 Mechanical Line Leak Detector. Model: FX1V Fill Sump SensModel: Mechanical Linee Lea Leak Detector. Model: FX1V 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 p type and model in Section E on page 2). Tank ID: 3-91 Tank ID: --D§-L X1 In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: LS3 Annular Space or Vault Sensor. Model: X Piping Sumprrrench Sensor(s). Model: 208 Piping Sump/Tmnch Sensor(s). Model: 206 X Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 X Mechanical Line Leak Detector. Model: FX1V Mechanical Line Leak Detector. Model: FX1-DV 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). Others eci ( p ty equipment type and model in Section E on page 2). Dispenser 1/2 Dispenser ID: 3 -71 Dispenser Containment Sensor(s) Model:208 :X:l Dispenser Containment Sensor(s) Model:208 XJ Shear Valve(s). X Shear Valve(s) ❑Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 4/5 Dispenser ID: 6 X❑ Dispenser Containment Sensor(s) Model:208 Dispenser Containment Sensor(s). Model:208 x❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chaints). Dispenser ID: 7/8 Dispenser ID: 9 X❑ Dispenser Containment Sensoria) Model:206 X Dispenser Containment Sensor(s). Model:208 QX Shear Valve(s). X Shear Valve(s). DDispenser 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 Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a copy of the(Check all that apply): ❑System set-up X❑Alarm history report Technician Name(print): DOUGLAS HARTY Signature: � . Certification No.: License.No.: Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8900 Shoal Creek,Bldg.200 Austin,TX 78757 Date of Testing/Servicing: 09/29/2004 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01