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SEP-17-2007 10: 10 Service Station Systems 408 938 8888 P.07 MonitorintoSystem Equipment irtifcation For Use By All Jurisdiclions Within The State of'Califnrnia Authority Cited. Chapter 67, Health and Safety Code,, Chapler 16, Division 3, Title 23, California Code of Regulaliuns This form must be used to document testing and servicing of monitoring equipment. A separate certific4t,QPreport most be prepared for eachxngniWring 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 Zip: 95242-4123 Facility Contact Person: xr1tjL A Contact Phone No.: (209) 369-3124,y� Make/Model of Monitoring System: it EMC Date of Testing/Servicing: -�1��7 B. Inventory of Equipment Tested/Certified Check the appropriate hexes to indicate specific equipment inspected/serviced: Tank ID Tank TDO 5 ❑ In-Tank Gauging Probc. Model: ❑ In-'funk Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular$pace or vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\"ITench Sensor(s). Model' a Pjll Sump Sensor(s). Model: ❑ Pill Sump Sensor(s). Moder techanical Line Leak DctcCtor, Model: LJ z --o 4 51Ciechanical Line Leak DctcCtor, Model: o ❑ kaectronic Line Leak Detector, Model: ❑ Electronic Line Leak Detector, Model; ❑ 'rank Overfill\High-Level Sensor, Model: ❑ fank Overfill\high-Level Scnsor, Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Otlicr(specify equipment type and model in Scction F nn Page 2). Tank ID•9 1 Tank TD: ❑ in-,rank Gauging Probe. Model: ❑ In-Tank Gauging Probc. Model: ❑ Annular Space or Vault Sensor, Model: ❑ Annular Space or Vault Sensor. Modcl. ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Moder Q Fill Sump Scnsor(s). Model: ❑ Filt Sump Sensor(s). Model: �fcchanical Line Leak Detector. Model: JX Z-400-14-7 _ ❑ Mechanical Eine teak Detector. Model; ❑ Electronic Line Leak Detector, Model: p Electronic Linc Lcak Detector. Model: ❑ Tank Overfill\High-Level Scnsor. Model: ❑ Tank Overfill\High-Level Sensor. Model: ❑ Othcr(specify equipment type and model in Scetion I-on Page 2). ❑ Other(specify equipment type and model in Section E on Pagc 2). Dispenser ID Dispenser ID; [I Dispenser Containment Sensor(s), Model: ❑ Dispenser Containment Sensor(s). Model; p Shear Valve(s), ❑ Shear Valvc(s). p Iaispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser 1D• Dispenser Ill' ❑ Dispenser Containment Sensor(s). Model; ❑ Dispenser Containment Senear(s). Model: ❑ Shcar Valve(s). ❑ Shear Valve(s). ❑ Dispcnser Gontainment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID• Dispenser 111)• C1 Dispenser Containment Sensor(s). btodcl; ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valvc(s). ❑ Shcar Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). -If tic 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.manufactures'checklists)neccs-wry to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,l have also attached a copy of the'. (ctreck all that apply): ❑ System set-up ❑ Alar Ihisto y reeyport Technician Nalne(print : Rand A Wilkerson Signature: u Mfg. Cert.#.: /¢3 L Yo y FCC# 5258560-UT Licensc.No.: 485184 Testing Company Name: Serv. Sta. Sys. Phone No.: 408 971»2445 Site Address: 2448 W Kettieman Ln. V_Lower Sacramento Date of Testing/Servicing: