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irTank ok)9Y MONITORING SYSTEM CERTIFICATION Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,.—alth and Safety Code;Chapter 16,Division 3 Title 23, Ca,,,.mia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility,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 the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: USA#03696 City: LODI CA Zip:95242 Site Address: 2448 W KETTLEMAN LN Contact Phone No:369-3124 @ LOWER SACRAMENTO RD Date of Testing/Service: 09/12!2003 Facility Contact Person: MGR-BETH Make/Model of Monitoring System: GILBARCO EMC Work Order Number: 2228417 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 1 Tank ID: 2 71 In-Tank Gauging Probe. Model: 2650960200 X In-Tank Gauging Probe. Model: 2650960200 X Annular Space or Vault Sensor. Model: 794390407 Annular Space or Vault Sensor. Model: 794390407 71 Piping Sump/Trench Sensor(s). Model: 25920000002592000000 Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model: 2592000000 2592000000 Mechanical Line Leak Detector. Model: FX1V Fill Sump SensModel: Mechanical Linee Leak Detector. Model: FX1V Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 61 SO X Tank Overfill/High-Level Sensor. Model: 61 SO Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). TanklD: 3 TanklD: X In-Tank Gauging Probe. Model: 2650960200 In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 794390407 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 2592000000 Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model: 2592000000 Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: FX1V Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model: 61 SO 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 : 1/2 Dispenser ID: 3/4 ❑Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: X❑Shear Valve(s). X Shear Valve(s) ZDispenser Containment Float(s)and Chain(s). —X-1 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ❑ Dispenser Containment Sensor(s) Model: 7 Dispenser Containment Sensor(s). Model: X❑ Shear Valve(s). Shear Valve(s). X Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: nDispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). 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 Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a copy of the(Check all that apply): System set-up report; F Alarm history report X❑ PRINTED NAME:JEFF CONGER SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01