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'WnY ONITORING SYSTEM CERTIFICATION Foy ise By All Jurisdictions Within the State of Californi6 Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16, Division 3 Title 23, California 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 09/12/2003 Date of Testing/Service: 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 ZI In-Tank Gauging Probe. Model: 2650960200 X Annular Space or Vault Sensor. Model: 794390407 Annular Space or Vault Sensor. Model: 794390407 X Piping Sump/Trench Sensor(s). Model: 2592000000 Piping Sumpffrench Sensor(s). Model: 2592000000 X Fill Sump Sensor(s). Model: 2592000000 Fill Sump Sensor(s). Model: 2592000000 Mechanical Line Leak Detector. Model FX1V FX1V' Mechanical Line Leak Detector. Mode: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 61 SO X Tank Overfill/High-Level Sensor. Moce! 61 SO Omer(specify equipment type and modei in Section E on page 2). Other(speciry equipment type and model in Section E on page 2). TanklD: 3 TanklD: X In-Tank Gauging Probe. Model: 2650960200 7 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 7Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: FX1 V 7 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 7 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). 7 Other(specify equipment type and model in Section E on page 2). Dispenser : 112 Dispenser ID: 3/4 71 Dispenser Containment Sensor(s) Mode:: 7 Dispenser Containment Sensor(s) Model: X❑Shear Valve(s). X Shear Valves) ❑X Dispenser Containment Float(s)and Chain(s) X Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 7 Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: XD Shear Valve(s). Shear Valve(s). X Dispenser Containment Float(s)and Chain(s). 7Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). 7Shear Valve(s). Dispenser Containment Fioat(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; ❑ Alarm history report XO PRINTED NAME:JEFF CONGER SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01