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SEP-17-2007 10:09 Service Station Systems 408 938 8888 P.02 ' MonitorinoSystem Equipment - 1,ri ification ];'or Use By All Jurisdictions Within The State of California Authority Cited., Chapter 6.7, Health and Safely Code; Chapter 16, Division 3, Title 23, Callornia Code of'Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or r�pQrt 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 system within 30 days of test date. A. General Information Facility Name: USA 68153 _ Bldg.No.: Site Address: 2448 W. Kettleman Ln. @ Lower Sacramento City: Lodi, CA Gip: 95242-4123 Facility Contact Person: Contact Phone No.: (209) 369-3124 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 5129107 B. Inventory of Equipment Tested/Certifietl Check the appropriate boxes to indicate specific equipment iaspected/serviced: Tank ID• Tank 1D• ❑ 1 Tank Gauging Probe. Model: ❑ h -Tank Gauging]'robe. Model: [Annular Space or Vault Sensor, Model: El Space or Vault Sensor. Model: Vping Sump\Trench Sensor(s), Model: ping Sump\Trench Sensor(s). Model: Z a 5 II Sump Sensor(s). Model: RO Fill Sump Senior(s). Model: 7-0 ' I,1Ftechanical I..ine leak Detector. Model: ❑ Mechanical I..inc I.eak Detector. Model: D Electronic Linc Leak Detector. Model: ❑ Electronic Linc Lcak Detector. Model: 1] Tank Overfill\High-Level Sensor, Model, p Tank Overfill\high-Level Sensor. Model: ❑ Other(specify equipment type and model in Scction 6 on Page 2). p Other(specifv equipment type and model in Section E on Page 2). Tank IQ; Tank ID L] In-Tank Gauging Frobe. Model ❑ In-Tank Gauging Probe. Model: uwlar Space or Vault Sensor, :Model: 'r 0 ❑ Annular Space or Vault Sensor. Model: P ping Sump\Trench Sensor(s). Model: 2.4�' ❑ Piping Sump\Trench Sensor(s). Model: VII Sunip Sensor(s). Model: Z+9_V_ ❑ Fill Sump Sensor(s). Model' Q Mechanical Line Leak Detector. Model: [3 Mechanical Line Leak Detector. Model: p Eleetmnic Line Leak DctcetOT. Model: ❑ Electronic Linc Leak Detector. Model: ❑ Tank Overfill\IIigh-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model; ❑ Other(specify equipment type and model in SCetion E on Pagc 2). p Other(specify equipment type and model in Section F;on Page 2). Dispenser[D• 1—L 1 Dispenser ID -?` `/ ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Modcl; ❑ Shear Vaivc(s), ❑ PM'Valve(s), jLelf5spenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and(:hain(s). Dispenser lD-s-- Dispenser I% p Dispenser Containment Sensor(s). Model; p Dispenser Containment Sensor(s). Model: ❑ car Valve(s). ❑ ',skar Valve W. p/Dispenser Containment Float(s)and Chain(s). ffDispenser Containment Float(s)and Chain(s). Dispenser iD Dispenser ID Q Dispenser Containment Sensor(s). Model; C] Dispenser Containment Scnsur(s). Model: p 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 manufacturer's guidelines. Attached to this Certification is information(e.g.mnufae(ures'checklists)necessary to verify that this information Is correct and a Plot Plan showing the layout of monituring equipment. For ally equi nt capable of generating such reports,I have also attached a copy of the; (cheek all(hat apply): ystem sct-up AI m histur report Technician Name(print)' Randy A Wilkerson Signature: Mfg.Cert.#.: nZ ,0 11CC# License_No.: 485184 Testing Company Name: Serv. Sta. Sys. Phone No,: (408)971-2445 Site Address: 2448 W Kettleman Ln. @ Lower Sacramento Date of Testing/Servicing: 5129107