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10/04/2004 02:58 2093651, 43 TANKNOLOGY PAGE 10 ""�-'- "—" • rMONITORING SYSTEM CERTIFICATION • For Use By All Jurisdictions l4 Kri the State of Califomia Au#roffty Cried.Chapter 6.7,Health and Safety Code;Chapter 16, Division,21 7711e 23, Califomle Code of Regulations Thia form must be used to document testing and servicing of monitoring equipment h more than one momitonng system control panel Is Installed at the facility,a separate CMIArallon of report must tb_prepared fpr each motoring avf(gm rnmrol panel by the technician who performs the work. A copy of this Tann must be provided to the tank system oanwi6peratorThe ownedoperaror must submit a copy of This form to the local agency raoulsdng UST systemawiglin 30 days of fast date. A-General Information Facility Name: USA#65 City LODI CA Yip:95242 Site Address: 25W W. LODI AVE. Contac(Phone No:3339834 LOWER SACRAMENTO RD. Facility Contact Person: MGR•SHARON Date of Teslingl5arvlm; 09!29/2004 Make/Model of Monitoring System: TLS-350 Work Order Number: 2232464 B.Inventory of Equipment Testerl/Certlffed Check the appropriate boas to indicate specific equipment inspected/serviced Tank ID, 1-87 Tank ID: 2-89 1XI In-Tank Gauging Probe_ Model: MAG X Io-Tank Geuging Probe. Model: MAG X Annular Space Or Vault Semupr. Model: LS3 Annular Space orVauh Senaor. Model: LS3 X Piping SumpTrench Sensor(s). Model: 208 Piping eumpMench Sonsor(a). Modal: 208 '91 Fill Sump Sensar(a). MMet 208 Fill Sump Sensor(s). Model' 208 Mechanical Line Leak Detector. Model: FXt V Mecharl1i Line Leak Detector. Model: FXt V Electronic Une leak Detector, Model• ElectmniC Line Leak Detector. Model; Tank OV rflluHigh-Level Sensor. Model: Tank Overfill(Hlgh-Level Sensor. Model: Other(specify equlpmenttype and model In Section E on page 2). parer(specify equipment type and model in Section E o+page 2). Tank ID; M1 Tank ID: In-Tank Gauging Probe. Model: MAG in-Tank Gauging Probe. Model: MAG X Annular Spade a Vault Senior. Model: L53 Annular Space orVauh Sensor. Model: X1 Piping Sonprfrench Sensa(s). Model; 208 Piping Sump/Trench Senaor(s). Model: 208 X Fill Sump Sensor(s). Model: 208 Fill Sump Sensogs). Madel: 208 X Mechanlml Line Leak Detector. Model: FX1V Mechanical Lire Leak Detecto,. Model. FX1-DV Electronic Line Leak Delachir. Model; Electronic Lim Leak DOWN. Model: Tank Overen/Hlgh-Laval Semler- Model: Tank OverdllMigh•Level Senear. Model: Omer(specify equipment type and model in Section E on page 2). Other(specrry equipment type and mdid I in Section E on page 2). Spenser Dispenser PX Dispenser Containment Senscr(s) Model:208 Dispenser conlalmnem Senear(a) Model;208 AX 3hwr Val"W. X Shear Valves) Dispenser containment Floats)and Chaln(s). olnpenser Containment Float(a)and Chaints). Dispenser ID: 415 Dispenser ID; 6 X['l Dkpenser ContalnmeMSereor(s) Mods1:208 Dispenser Containment Seneorts). Model:208 X Shear Valve(;). Shear Valve(;). Dispenser Comalnment Floats)and Chaln(5). Dispenser Containment Manila)am Chaln(s). Dispenser ID: 7/8 Dispenser ID: 9 Dispenser Comainmem Senapr(S) Moea1:208 X Dispenser Containment Sansa(s). Model;208 Q shesrvalve(s). X Shear valve(s). Dispenser Containment Floats)ane Chain(s). Dispenser Containment Floats)and Chain(s). 'If the facility contains more tanks or dispenser$,Copy this form. Include information for every tank and dispenser at the facility. C. Csrtlfkcafion I cedify,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 verity that this information is correct and a Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,1 have also attached a copy of the(Check all that apply): System set-up report; Alarm history repoy,R-'�`�X� PRINTED NAME-DOUGLAS NARTY SIGNATURE: .. COMPANY: Tanknology PHONE NO: (800)8004833 page 1 of 3 Basad on CA form dated 03101