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MONITORING SYSTEM CERTIFICA D For Use By All Jurisdictions Within the State of Califor a Authority Cited-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 reoortUL2kllpared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 3AtactdateENTAL HEALTH A. General Information nFPARTMENT FacilityName: Valley Pacific Bldg.No.: N/A Site Address: 930 E. Victor Rd City: Lodi, CA Zip: 95240 Facility Contact Person: Mike Eliason Contact Phone No.: (209)993-8793 Make/Model of Monitoring System: Vender Root TLS-350 Date of Testing/Servicing: 03120117 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicide specific equipment inspected/serviced. Tank ID: T-6 87 Tank ID: T-7 87 10In-TankGauging Probe. Model: VR-Mag-Plus SIn-Tank Gauging Probe. Model: VR-Mag-Plus S Annular Space or Vault Sensor. Model: VR-420 Z Annular Space or Vault Sensor. Model: VR-420 S Piping Sump/Trench Sensor(s). Model: VR-208 Z Piping Sump/Trench Sensor(s). Model: VR-208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: S Mechanical Line Leak Detector. Model: LD-2000 S Mechanical Line Leak Detector. Model: LD-2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: S Tank Overfill/High-Level Sensor. Model: OPW Flapper Valve Z Tank Overfill/High-Level Sensor. Model: OPW Flapper Valve ❑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: ❑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 Seasons). 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: ❑Tank Overfill/High-Level Sensor. Model: ❑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). Dispenser ID: #1-2 Dispenser ID: #33 ❑Dispenser Containment Sensor(s). Model: N/A ❑Dispenser Containment Sensor(s). Model: N/A S Shear Valve(s). Z ShearValve(s). S Dispenser Containment Floats)and Chain(s). 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). ❑ShearValve(s). ❑Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Seasons). Model: ❑Dispenser Containment Sensor(s). Model: ❑ShearValve(s). ❑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 Plot Plan showing the layout of monitoring equipment For any equipment capable of generating such reports,I have also attached a copy of the report; (check all that apply): ®//System set-up ®Alarm history report Technician Name(print): RICHARD THOMAS Signature: Certification No.: 834022 License.No.: 803616 Testing Company Name: CGRS,Inc. Phone No.:916-991-1100 Testing Company Address: 5444 Dry Creek Rd.Sacramento,CA 95838 Date of Testing/Servicing: 03120117 UN-036— www.unidocs.org Rev.01/17/08