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MONITORING SYSTEM CERTIFICATION <br /> or Use By All Jurisdictions Within the State of California <br /> Authority Cited:Citapter 6.7.Health and Safery Code: Chapter 16,Division 3,7-ztle 23, California Code ofReguiarions <br /> This form must be used to document testing and servicing of monitoring equipment.A senarate certification or report must be orenared <br /> for each mointotine system control panel by the technician who performs the work. A copy of this form must be provided to the tank <br /> system ownerlopaator. The ownetloperahoi must submit a copy of his form to the local agency regulating UST systems within 30 <br /> days of test date. USA PETROLEUM #65 <br /> A. General Infos 2500 WEST LODI AVE. Bldg.No.: <br /> FacilityName: — LODI, CA 95242 ` <br /> Site Address: Zip: <br /> Facility Contact Person: Contact Phone No-: <br /> MaketModel of Monitoring System: ) Date of Testmg/Servicutg: <br /> 8. Inventory of Equipment Tested/Certified <br /> Qum nor,Almoptlate boas to - <br /> Tank M: Tack ID- v <br /> p �lo-Teok Crnrging Prahe. Model N`Tih-TmkGwgipg probe. Model <br /> I! -Annag Spate or Vault Semor_ Model: QrAtwa}aSpace or Vwli Sensor. Model O <br /> .Srunp/TrmdeS <br /> +3-Pip Model - -off J�ipis10 Smnp/Dznth Sasor(s)- Model: <br /> $F.it Sa <br /> ump Ssor(s). Model: Fi Fid Sump Sema(s)- <br /> Model= <br /> y]-MetDnoical tine Irak Detecmr- Mom 150Mech®ui lane LeakDebmw Model: v <br /> M, ❑ 0,=t nle Lmel�- e1)t . Mold= D P.lmronic IineLeak Detector- Model: <br /> 7>fad oycrim I IEgh-level Semor. Mode: j:6,Tmk 0,,,W IIES-j^,d Sensor. Model <br /> ❑Other(Specift equalmen(Spec— and model in Section E oa P 2). k ❑ Other-twecify wd model in Section E on Pat 2)- <br /> Tank M: - k Tank ID: t`5 <br /> Qin-Toot Gat�agFmbe. Model: ;1ID-TavkCmpng Robe. Model <br /> �Amwl�Space or V melt 5eamr. ModelOrAr pular Space or Vault Susor. Model' <br /> SI'Piiang sump I Trench Somor(s). Madel: - OS� *piping Sump f Trench Seasot(s)_ Model: <br /> ill Sump Sensor(s). Model: '- ArFill Sure semor(s). Model: <br /> t hamiW line Leak Detector. Mudd: (� $�la1aa®tad law 3rskDetec[a<- M°drl <br /> . Q17ewoaie l.irtcLakDateaa. Madel--p�--�-- ' Q Biecaumc line Leak Detector. Model: <br /> lWffank Otzrfill/Wigh-Level Sensor- Model: Qrfank 0fill lust lsv lsensor- Modelr=Pa_" <br /> Q Other and model in Sermon E oa 2). D OWe( mai and mode)in <br /> I)ispcnscr ID: > � // <br /> bLDispouer CmrUhmtmrSmsor(s). Modet lilsDispm�Cmtmmratt Seaaa(s)- Model--., L <br /> 1assbear Valves) <br /> Q t�Vat LV�C sanra:s®mt Floar(s)and Chum(s)- it Csatmment Flows)and Chain(s)- <br /> -/— <br /> Dispenserur. <br /> { v�Coniainmem Srnsor(s). Aiode1: ( HcDnpe Cwmmnm r Sen=(s)- Mond: /� + <br /> 'aShear Valves) i -Shear Valtm(sj <br /> ❑ - ComainmmtFloa(s) �em(s) ❑DispensetCalarannotFioat(s Chaws). <br /> Dispenss ID: - » �- i� <br /> QrDispeosei Cwiaiommt Sensor(s). Mn&L- !/ Comaiomem Senmr(s). Model <br /> -a Shear Vahse(s} wShear Vaive(s). <br /> t QDispmsesCmdiamnrnt Flows)ond Chmml) QDi ts�Cmtainmmt Fows)aBd Ck2m(s)_ <br /> 'If the facility contains mom tanks or dispensers-copy this form. Include inforaultim for every rank and dispenser at the faerbty. <br /> C. Certification.I certify that the egtdpmeat identMed in this,document was uupetleNserviced in accordance with the manufacturers' <br /> guaddmes. Attached to this Certificsdon is information(e$.meitlEaaaremb Checkftsts) to - that this information is <br /> correct and a Plot Plan shvwing the blow of mno(t0ift e110111111MBIL Fa'any - such npxts,l hate also <br /> attached a mpy d the ( drat�?��'): set-up <br /> Technician Name(print): P,1 t t 1 Sigmture: <br /> Certification No.: license-No. (J"✓ . <br /> Testing Company Name: `^/ L / Phone �/�j <br /> Site Address: 560 t'`/e f o • • p�� Date of Testing/5ervicing:�30—a2. <br /> Pagel of 3 03101 <br /> Monitoring System Certification <br />