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MONITOUNG SYSTEM CERTIFI*kT 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, CaRonCbg�Vems This form must be used to document testing and servicing of monitoring equipment. A separate certification o rtLiAk R®fkpared for each monitoring system control panel by the technician who performs the work. A copy of this forma rovided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST s ust E"4ARiTane. A. General Information MMIPSERVICES Facility Name: 76/ Bldg.No.: Site Address: 1111 E Kettleman Ln City: Lodi Zip: 95240 Facility Contact Person: Jivtesh Gill Contact Phone No.: (209) 369-3633 Make/Model of Monitoring System: EMC Date of Testing/Servicing: 1OIJW2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates cific a ui ment inspected/serviced: Tank ID: 87 Unl TanklD: 91 Unl ®In-Tank Gauging Probe. Model: VR ®In-Tank Gauging Probe. Model: VR ®Annular Space or Vault Sensor. Model: 420 ®Annular Space or Vault Sensor. Model: 420 ®Piping Sump/Trench Sensor(s), Model: 208 ®Piping Sump/Trench Sensorts). Model: 208 ❑Fill Sump Sensm(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: LD-2000 IR Mechanical Line Leak Detector. Model: STP-MLD ❑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: Diesel Tank ID: 0 In-Tank Gauging Probe. Model: VR ❑ In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s), Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: M Mechanical Line Leak Detector. Model: LD4000 ❑ 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: 314 ❑Dispenser Containment Smsor(s). Model: ❑Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). 21 Dispenser Containment Floats)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ®Shear Valve(s). 0 Shear Valve(s). Z Dispenser Containment Floats)and Chain(s). 0 Dispenser Containment Flom(s)and Chain(s). Dispenser tD: Dispenser ID: ❑ Dispenser Containment Sencor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). [IShear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Cbam(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): ® stem set up ® Alarm history report Technician Name Gavin Williams Signature: F! Certification No.: 8016684-UT License.No.: '-656774 Testing Company Name: HMC-HBnderson Maintenance Company Phone No.:(209) 467-7573 Site Address: Date of Testing/Servicing: 10/,W2009 Page 1 of 3 30