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MONITRNG SYSTEM CERTIFIATION RECEIVE® For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code q{Repulatjogs �, This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control Panel by the technician who performs the work. A copy of this form must be provided to thk� 1�lU"rA'�9Afdi°fH The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test aN�e�.��PERMIT/SERVICES A. General Information FacilityName: Wine Country76 Bldg.No.: Site Address: 1111 E. Kettleman Lane City: Lodi Zip: ysp yiv Facility Contact Person: Sonny Contact Phone No.: (209) 369-3633 Make/Model of Monitoring System: Veeder root TLS 350 Date of Testing/Servicing: 1012012011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: T-1 87 Tank fD: T-2 91 ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 420 Z Annular Space or Vault Sensor. Model: 420 Z Piping Sump/Trench Senors). Model: PA02592000010 Z Piping Sump/Trench Sensor(s). Model: PA02592000010 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: 99LD2000 Z Mechanical Line Leak Detector. Model: 99LD2000 ❑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). Tank ID: T-3 DIESEL Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 420 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: PA02592000010 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: LD2000 ❑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: 3/4 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). Z Shear Valve(s). ®Dispenser Containment Float(s)and Chain(s). Z Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ®Shear Valve(s). " Z Dispenser Containment Float(s)and Chain(s). Z Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Senors). Model: ❑Dispenser Containment Seasons). Model: ❑Shear Valve(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): Robert Barnhart Signature: /z t(o Certification No.: 835969 License.No.: 883706 Testing Company Name: Reliable Petroleum Services Inc. Phone No.: (209) 845-8586 Testing Company Address: 11930 Horseshoe Road, Oakdale CA 95361 Date of Testing/Servicing: 10/20/2011 Page 1 of 3 Rev(2/08)