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MONITNG SYSTEM CERTIFITION se By All Jurisdictions Within the State of Califomi Authority Cited:Chapter 6.7,He h and Safety Code;Chapter 16, Division 3 Title 23, C377fornia 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 perforins the work. A copy of this forth must be provided to the tank system owner/operator. The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: USA#65 City: LODI CA Zip:95242 Site Address: 2500 W.LODI AVE. Contact Phone No: 366-0703 LOWER SACRAMENTO RD. Date of Testing/Service: 10/04/2005 Facility Contact Person: MGR-BOBBIE Make/Model of Monitoring System:TLS-350 Work Order Number. 2238773 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 1-87 Tank ID: 2-89 X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: LS3 Annular Space or Vault Sensor. Model: LS3 71 Piping Sump/Trench Sensor(s). Model: 208 Piping Sumpfrrench Sensor(s). Model: 208 71 Fill Sump Sensorts). Model: 208 Fill Sump Sensor(s). Model: 206 -39 Mechanical Line Leak Detector. Model: FX1 VFX1 V Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank OvefilVHigh-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). Tank ID: Tank ID:—L-QIL— R1In-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: LS3 X Piping Sump/rrench Sensogs). Model: 208 Piping Sumpfrrench Sensor(s). Model: 206 X1 Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 206 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 OverfilUHigh-Level Sensor. Model: Tank overfilVHigh-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). D Other(specify equipment type and model in Section E on page 2). Dispenser 1/2 Dispenser ID: 3 MDispenser Containment Sensors) Model:208 :Xj Dispenser Containment Sensor(s) Model:208 X❑Shear Valve(s). X Shear Valve(s) ❑Dispenser Containment Floats)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 4/5 Dispenser ID: 6 FX-1 Dispenser Containment Sensor(s) Model:206 Dispenser Containment Sensoria). Model:208 X❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 7/8 Dispenser ID: 9 MDispenser Containment Sensor(s) Model:206 X Dispenser Containment Sensor(s). Model:208 FX Shear Valve(s). X Shear Valve(s). Dispenser 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❑Ala"history report Technician Name(print): DOUGLAS HARTY Signature: Certification No.: License.No.: Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8501 N.MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 10/04/2005 Page 1 of 3 Based on CA form dated 03/01 Monitoring System Certification