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111111i"Idn/ nokligy MONITORING SYSTEM CERTIFICATION 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 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: BEACON#67080 City: LODI CA Zip: 85242 Site Address: 2448 W. KETTLEMAN LN Contact Phone No: 369-3124 Facility Contact Person: MANAGER Date of Testing/Service: 09/04/2002 Make/Model of Monitoring System: GBCO EMC Work Order Number: 2223477 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced ----------------------- Tank ID: REGULAR Tank ID: PLUS X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: VR 407 Annular Space or Vault Sensor. Model: VR 407 X Piping Sump/Trench Sensor(s). Model: VR 208 Piping Sump/Trench Sensor(s). Model VR 208 X Fill Sump Sensor(s). Model: VR 208 Mechanical Line Leak Detector. Model RJ FX1 V Fill Sump Sensor(s). Model: VR 208 Mechanical Line Leak Detector. Model: RJ FX1 V 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). Tank ID: Other(specify equipment type and model in Section E on page 2). Tank ID: X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: TR-4-0 7In-Tank Gauging Probe. Model: X Piping Sump/Trench Sensor(s). Model: VR 208 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: VR 208 X� Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: RJ FX1 V Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Electronic Line Leak Detector. Model: Other(specify equipment type and model in Section E on page 2). Tank Overfill/High-Level Sensor, Model: Other(specify equipment type and model in Section E on page 2). Ispenser 11J. 1/2 Dispenser ❑Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: X❑Shear Valve(s). X Shear Valve(s) Dispenser Containment Float(s)and Chain(s). X Dispenser Containment Float(s)and Chain(s). ❑X Dispenser ID: 3/4 Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: X11 Shear Valve(s). Shear Valve(s). X Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: 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). C. Certification If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. 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 0 PRINTED NAME:KEVIN MATLOCK /l,� � / SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 pagell of 3 Based on CA form dated 03/01