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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of CaWomia .4rrrhori[y Cited.'Cluipler 6.7.Heafth and S*ry Code:Chapter 16, Division 3, ride 23, California Code of Regulafionr This form mustbe used to document testing and servicing of monitoring equipment.A separate cortificetion or report must be orerared for each monitoring system control nanei by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operr':u roust submit a copy of this form to the local agency regulating UST systems within 30 days of tut date. A. General Information VALLEY PACIFIC CARDLOCK 152 Facility Name: 930 E. VICTOR RD. Bldg,No.: Site Address: LODI, CA 95240 _ Zip: Facility Contact Person: -7�� -Zontactone o.:� ) Make/Model of Monitoring SyDate of Testing/Servicing: / il��_I B. Inventory of Equipment Teste&Certified Cbwkthea ro 'atehmo:s 1p' cola it went' atedtserviced: Tank ID: Pti Tank ID: ,D�A; ularpaceGauging Probe. Model: _ ❑ In-Tank Gauging Probe. Model: p Aanuler Spar or Vault Sensor. Model: �""t ❑ Annular Space or Vault Sensor. Model: , i2 i g Sump/Trench Swsor(s)_ Model: f- ' D Piping Sump/Trench Seasor(s). Model: O Fill Sump Smsoi(s). Model: ❑Fill Sump Seusce(s). Model: 9-Mechanical tine teak Detector. Model: - O Mechanical tine Leak Detector. Mode): ❑meennnrc line Leak Daestor. Model: ❑E(ecnooic Line Leak Derecrm. Model: -12-Tank Overfill t F+gh-Levet Sensor. Model:— r ❑Tack Overfed l High-Level Sensor, Model O Other(specift equipment tried model in Section on Pa 2). ❑ Other(specify equipmentlype.and model in Section E on Pne 2). Tank IN ..,✓ Taidt ID: ,W-)n-Tank CW&ltPro be, Model: ❑lri-Tank Gauging Probe. Model: M Annular Space a Vault Stmaor. Model:— ❑Atmula`Sparc«vaulr Sans rr. Model: .b Piping Sorn p/Trwch Sensor(s). Model: -1 ❑Piping Same/Trench Seasor(s). Model: ❑Fill Sump somr(s). Model: ❑Fill Sump Sensor(s). Model: ZMechanical Line Leak Detector. Model: Tom— 0 Mwbamcat line Trak Demeans. Model: ❑ 'elite Lok DetoRon. Modd: 4 Elocamdp lineI.eakDeteoaor. Model: ark Ovoxh)1 I HiEh-Level Seuor. Model:_._ tL2 r- ❑ TW&Overfill/lligh-Level Sensor. Model: ❑Oolwr i o and model in SectSoa E on Pace 2). ❑Do=isg=ffy Cori and model in Section E on P e Z. Dispenser ID: Diq m er 11): DupmssCtuitainateatSmsor(s}. Model: _ (2DispavW Caompneeret Seasor(s). Model: az:t��sb�car valve(s). 'a'shw valves} brlir Containment Rioat(s and c u n(s). A:Dispenser Containment Fl s and Cbain(s). DSspepmrlD: — DispesuvlD: ❑Dispenser Comainmeat Scnsor(s). Model: O Dispenser Conainmam Seamr(s). model. 04hear vaiw(s). O Shear valixtsl Q:Uispenscr Containment s)and Chains. ❑Dispenser Containment Floats and Chain(s), _Dtspe ID: 1JdtiginaerlB: S7 Dispenser Containment Suisa(sJ. Model• ❑Dispeasar Containment Seosor(s). Model: Wshear Valve(s). U Shear Valvc(s). set cn marnntent FloW&l and Chain (2 Di W Containment Floats)and Cbnin(s. .0 the facility contains more tanks or dispenser&copy this form. include inibmusion for every rank and dispenser w the facilSry. C. Certification-I certify flat the als*mew identNkd in this dmmxxt wasinspocted/m7ked In arcordastce with the mmutactmera' gcdddba Attached to tHs Cerfillotkn Is Iafasmatim(ag mmau@(imus'rhecUlft)scaeea ay to Vn*that this k&rmxbm is cormatend a Not Ptah siwwlagthe bgwt afmoottatin Far sw attached acopy etthe egwrt:(check as tlau C 7 of such report I have also /{ �Y): y�M-UP report Teckmician Name(print): r7�7 /1/P i M P1.�P r Signature: _------------ Certification No.: T T License No.: Z7 �t , / Testing Company Name: l �✓.1 K.' / F?-K Phone No.:t 70�/ '�`Y &—(0IS� Site Address: 930 E , 1c-let, t'1d, 1—° 044. ' Dam of Teshug/sanwiag: /. /,gy Page 1 of 3 os/or �OtfifAttirig System Cer�ifca{toa