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,%me -! MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cite&Chapter 6 7,Health and Safety Code;Chapter 16,Division 3, Title 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate.certification or report must be Kepared for each monito system control Mnel by the technician who performs the work.A copy of this form must be provided to the tank- system anksystem 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:VZB-LDIKCA Bldg,No.: Site Address:2500 West Turner Rd. City:Lodi Zip: 95242 Facility Contact Person:Jonathan Pakele Contact Phone No.: 9I6 439-6042 Make/Model of Monitoring System:Pneumereator TMS-2000 Date of Testing/Servicing: 4 f 25 12 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID-. UST Diesel Tank ID- In-Tank Gauging Probe. Model: (j In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: -610 ❑Annular Space or Vault Sensor. Model. ®Piping Sump/Trench Scnsor(s). Model: ( ) ❑Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: a Tank Overfill/High-Level Sensor.Model: ELEC RONIC-Wnc'rtntucfu. ❑Tank Overfill/High-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 11); ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: C] Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: a Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor.Model: ❑Tank Overfill/High-Level Sensor.Model: C]Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s).Model: ❑Dispenser Containment Sensor(s).Model: © Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s).Model: ❑Dispenser Containment Sensor(s).Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s).Model: ❑Dispenser Containment Sensor(s).Model: (w] Shear Valve(&). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(&). *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 Plot Plan showing the layout of monitoring equipment.For any equipment capable f generating such reports,I have also attached a copy of the report, (check all that apply)! N System set-up report; N m story �o Technician Name(print): Paul McLane Signature: Certification No.: 5238651-UT License No.: 703190 Testing Company Name: Sunwest Engineering Inc. Phone No.: 909 594-9850 Page i of 3 03/01