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YS MONITORING SYSTEM CERTIFICATION SEC 2 4 Z For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Health and Safety Cotte;Chapter 16,Division 3,Title 23,California Code of Regulations rR�HE�LT H t This form must be used to document testing and servicing of monitoring equipment.A art certification or reuort must be oreoared.faeettt ��T �.�rPm control Hanel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator nc .� %?iA must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information County: San Joaquin Facility Name: Arco Harney Ln City: Lodi Site Address: 255 E HarneyLane Contact Phone Facility Contact Person: Date of Testing/Servicing: 6/20/2018 Make/Model of Monitoring System: TLS 350 B. Inventor, of Equipment Tested/Certified Tank ID: 87 Tank ID: 91 ®In-Tank Gauging Probe. Model: 209 ®In-Tank Gauging Probe. Model: 209 or Vault Sensor. Model: 303 ®Annular Space or Vault Sensor. Model: 303 ®Annular Space ®Piping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model: 208 ® ®Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 ❑Mechanical Line Leak Detector. Model: C1 Mechanical Line Leak Detector. Model: i ®Electronic Line Leak Detector. Model: 8484 ®Electronic Line Leak Detector. Model: 8484 ®Tank Overfill/High-Level Sensor. Model: 001 ®Tank Overfill/High-Level Sensor. Model 001 ❑()thcr(spccif) equipment t}pe and model in Section E om PaRc 2 t ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: DSL ®In-Tank Gauging Probe. Model: 209 [1 In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ®Annular Space or Vault Sensor. Model: 303 []Piping Sump/Trench Sensor(s). Model: ®Piping Sump/Trench Sensor(s). Model: 208 ❑ Model: Model: 208 Fill Sump Sensor(s). ®Fill Sump Sensor(s). 0 Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: 8484 [3 Tank Overfill/High-Level Sensor. Model: ®Tank Overfill(High-Level Sensor. Model: 001 Other(specify equipment type and model in Section I em Page 2), ❑Other(specify l equipment type and model in Section E on ale 2) Dispenser ID: 3i4 Dispenser ID: 1/2 ® Dispenser Containment Sensor(s). Model: 208/ ®Dispenser Containment senwr(s). Model: 208/304 ❑Shear Valve(s). ®Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser(untainntent 110,1tul and Chain(s). Dispenser ID: 7/R Dispenser ID: 5/6 ®Dispenser Containment Sensor(s). Model: 208/304 ®DispenserContainmentSensor(s). Model: 208/303 ®Shear Valve(s) ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s) ❑Dispenser Containment Float(;)and Chains) Dispenser ID: 9,10 I1 l2 Dispenser ID: 13,14,15,l6 ® Dispenser Containment Sensor(s). Model: 208/304 Z Dispenser Containment Sensor(s). Model: 208/304 E Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s) ❑Dispenser Containment Float(s)and Chain(s). _ (heck the appropriate hoses to indicate specific equipment inspected/serviced: C. Certification - I certify that the equipment identified in this document waseinspected/serviced checklists)inecessary accordance with rify that the manufacturers' guidelines. Attached to this Certification is information (e.g. this information is correct and a Plan showing the layout of monitoring equipment. For equipment uip a Alarm historygenerating repOCsuch reprts,I have also attached a copy of the report;(check all that apply): ® Y set-up p Technician Name(print): James A Williams Signature: Certification A32464 License No.: 4 59 Testing Company Name: B.Z.Service Station Maintenance Phone No.: (916) 371-2380 Site 1041 Triangle Court West Sacramento,CA 95605 Date of Testing/Servicing: 6/20/2018 Monitoring Certification Test Report I of 5