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OC:T-25-2007 17:54 CITY OF LODI 209 333 6710 P. 16 ' MONITORING SYSTEM CERTIFfr ,TION !ru se• 6y.•10nrlyelictiunsWilhin.111t,.'1uteinf'Ca/ifr),„ra Aulhvrily Cited: Chapter 6.7, Health and Sifely Code; C'hoplur 16, Division 9, Tide 23, Calijornler C ocle uJ'Rn ulcrrivrzs This form must be used to document testing and servicing of monitoring equipment. & $eUgrAte:enrtification or report must be d for each monitoring system control by the technician who performs the work. A copy of this form Must be provided to the tank system owner/operator. The oWer/operator must submit a copy of this.'form to the IocAl agency regulating USX systems within 3o days of test date. A. Generallnformation Facility Name: VT OF DI AP YAl:7—b Bldg.No.: Site Address: 13'3 S, . L%A M Lt-A City:_1-cD1 zip: q6 Facility Contact Person: /V/1Contact Phone No.: 335 X'ZlJr10 ( ) tom Make/Model of Monitoring System: � � o�T '(us a5tbate of Testing/Servicing: 13 inventory of Ectuipmeat TOsted/Certified - Check thea re slate hazes to Indieate s iltc a ui ment im ted/serviced: Tank ID' M Q i 1J Tank 1D: 1�L• f� (nrTank Gauging Probe. Modcl: - - I Jld In-Tank Gauging Probe_ Model: Annular Space or Vault Sensor_ Model: Ig Annular Space or Vault Sensor.. Madel; Z� Piping Sump/Trench Sensor(s). Model: JR Piping Sump/Ticnch'Sengot s): Model: ]l Fill Sump SensortsY Model: ❑ FilrSUmp Sensor(s)' Model: s : I. gt Mechanical Line Leak Detector. Model: LP7,000.. Q4 Mechanical Ligt'LeakDefedtor. Model: -Mt`O -� C] klectronic Line Leak petector. Model: laJ Electronic Line.Leak Detector Mhdel: 0'Tank Ov0 ill l High-Level Sensor. Model: ❑ Tank Overfill/ 1igh-Level Sensor. 'Model: ❑ Other(specify equipment a and model in Section E on Pa' 2);” ❑ Other(specify a ui Merit t" and I in Section Eon Pa e.2). Tank tD: B7 Mi P44 o," Tank II): "Ci 11- J1 In-Tank Gauging Probe. Model:>K Rra I Cl In-Tank Galtgirig Probc. Model: At Annular Space or Vault Sensor_ Model' Annular Spate or Vault Sensor. Model: &Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model. > O Fill Sump Sensor(s). Model: Ll Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model; (3 Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Q Electronic Line Leak Detector. Modcl: O Tank Overfill/High-Level Sensor. Model: O.4ULk Overfill/High-LeveJ Setteor. Model: AT SeW t ❑ Otherfspecify equipment t and model in Section E on Pa 2). Q Other(s cr e l ent type and model in Section E on Pae 2). Dispebser ID: 1 4 - L?�hS' +A(Cs'SEt- Dispenser iD; Dispenser Containment Sensor(s). Model: C] Dispenser Containment Sensor(;), Model: 01 Shear Valve(s). Cl Shear Valve(s). j 0 Dispenser Containment Float(s)and Chain(s). U Dispenser Containment Floats and Chains_ Dispenser]D: y Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: Cl Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). CI Shear Valve(s). ❑ Dispenser Containment Flont(s)and Chain(s). Cl Di riser Containment Floats and Chain(s), 136peaser ID: DispenserlD: ❑ Dispenser Containment Scnsor(s). Model: ❑ Dispenser Containment Senmos). Model- ❑ Shear Valvc(s). Cl Shear Valve(s). C3DIspenser Containment Float(s)and Chain(s). ❑ RiMnser Containment Flows)and Chain s). *Ifthe facility contains morn 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. maoufac#urers' checklists) necessary to verify that this information is carnet and a Pilot Plan showing the layout or monitoring egoi meet. For arty equipment capable of generating such reports,)have also attached a copy of the report;(check all that'apply): W to sSL-ul2 19 Alarm history report Technician Name(print):_.A/V€�;�+„,,, Signature: Certification No.: f/E3 '� ` License.No..-A-- Testing -A-- du '14�•r�r Testing Company Name:. ATrlrr,�q--Tes= Phone No.:(20 )_' ±/- o Site Address: Date of Testing/Servicing: Page 1 of 3 " 0310 t Monitoring System CertiFcstion A. Results of Testing/Servicing i