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MONITORING SYSTEM CERTWATION <br /> ?or Use By All Jarisdfctiona VidLin die State ofCalifomia <br /> Aurhortty Cited:Chapter 6.7.Health and Sgfery Code:Chapter 16.Division 3,Tide 23, California Code ofRegutatiow <br /> This forst most be used to document testing and servicing of monitoring equipment.A separate conifioatiopo report must be re oare <br /> rnd <br /> for each monitoring system control Hanel by the technician who performs the work. A copy of this form must be provided to the tank <br /> system owner/operator. The owner/operetor roust submit a copy of this form to the fora)trgency regulating UST systems within 30 <br /> days of test date. _ ---_- <br /> A. General information USA PETROLEUM #65 <br /> Facility Name: 2500 WEST LODI AVE. _ B)dg,No.: <br /> LODI, CA 95242 <br /> Site Address: Zip: <br /> Facility Carted Person: [C�onticctt Phone No.:(_J <br /> Make/Mode)of Monitoring System: ��Q� �j -`flare of TeMng/Servicing: _&Jp'�2j <br /> B. Inventory of Equipment Tested/Certified 5/t� 705x/311 g6C5NI <br /> cie&rbe bt, to <br /> •Tank ID: Tmk)D: C/ <br /> ht-Tack(sauC3ng ProLc. A oriel: ❑ In-Tauk Gauging Pmbe- Model: <br /> 7 Amolar Sprxa Vaoh Sensor_ Mode ❑AmularSpace or Vault Sensor Model <br /> D Pining sump/Tzencb Sensor(s)- - ❑IKpingsunprnewhseasoc(sj. Mod-1: <br /> D nil Sumps .. odef: <br /> ❑ Mecbeniea([ane[catkq y- a FM sump Sensm(s)- ,•,�-'°Mudd: <br /> Q Elegronic lint lsak - LlMechamad tine treat Model: <br /> MWd: D eiecaomc linelealt Modell <br /> ! OT. OvetIDiffH Seaver. Model DTani Ovafip.Pl$pp-Txvd Sensor. Madel <br /> O(haa( 4WAkandel(n Sudan E on Fame 2). 1 ❑ Cdxr(wc&v <br /> Tank ft - 'model is Section E on P 2). <br /> Tw&]D- r <br /> p� D Io-Tank gingPmb� Model- ❑ht-Tank fmgmg Probe- Moddd <br /> F D AnWAN Spue or Vett sensor. Madel ❑Atmnlar Space or Van t Sensor Mode1- <br /> F 13 Piping Sl V t Tracb sensods). a Pipm' g Smq,t Tied Seo,ar(sj. Model: <br /> 0 Fw Stump Sensa(s)- odd: ❑Fill Sump Smmr(s), Model <br /> ❑Mem Lme leak Det Maki: ❑Mechanicet line I&*Demeter. Mpdet: ✓_ <br /> ❑accuumctiwLesk Mall: ❑Flaan®c line Detector_ Modd: <br /> ❑Tank Os25H/ vel Sensor. Model: ❑Tankihsxfill/flip},-Itvd Sensor Model:- <br /> ❑OilserecifreQUIPERN=and mpde3 in SCCuan E on 2)- ❑Other <br /> avdmold in Section E on Pane 2). <br /> Dispenser ID: Dkpenwr M, <br /> �k'bisPmsa CpSensor(s). Model- t �g p py � sModel: <br /> aam Valvc(s)- ❑ Shim Vahx(s). <br /> ❑ Conriro�nt Fioat(sja (s). O - Containment Floeds and Cbain(s)- <br /> DnpeuserID DIVe>aa Mr <br /> J?910pe0scr Caft"i^nwnt Sensor(s). jiodrl- - ❑Dispenser Containment Smmr(s). Model p <br /> J�4'hear Valvc(s) - ❑Sear Valta:(s). <br /> ❑ Com>®rnt Pkat(s)and - sl ❑ Comainmrat and t3ain(s). F <br /> cDispassa m: <br /> ! Cmtenment Seosor(s). Model: ,(� SID: <br /> alve(sl ❑llisQssa Containmem Seawmr(s). Mudd: <br /> D S]rem Valvc(s). , <br /> (:�oeaiommc FmY(sl amd Ciniu(S). O - Coatanm®t Fiom(s)and Chm(s)_ y <br /> •If the lanliry c,mmensmaac tanks ordiaprnsva,copy tms form indade i>ffmrmtion foretwy tauk and mso®sa&the facility. <br /> (r. CertlllCal]�n-I certify that the equipment identified in this document was inspectedlservieul in accordance with the manufacturers' <br /> guidelines. Atached tm this CertiHcatfon is information leg.mami[acmrrrs' ehocklists) necessary to verify that this information is <br /> rnrren and a Plat Ylao <br /> at�cLed arnpy tithe � ( lmu tttaoitoting Far arar t jOLli of gtmeatimg sad taporls.I have also <br /> Tecimidan Name(print): Signature: '.- <br /> Certification No.: License.No.: C, jr p /- <br /> Testing CompNome: K -�F_[' Phone No.:( /07 } L/LlllJ—�ISI <br /> Site Address:eZSO Q (w)r CT n, r9✓h f C_.DA/„Ci9 lite of TestenglSa via;ng:-LIJant/ <br /> Page I of 3 - <br /> Monitoring system Certification03101 <br />