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SEP-1,7-2007 10: 11 Service Station Systems 408 938 8888 P. 10 MonitorinoSystem Equipment ertification For Use By All Jurisdiclions Within The State of Califr)rnia Authority Cited: Chupler 6.7, Health and Safely Code; Chupler 16, Division 3, Title 23, C.'alifnrnia Code of Regulations This form must be used to docuulent testing and selvicing ormonitoring equipment. A separate certif ati 11 r report must he l2rrenared for each monitoring,,systen,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 dare. A. General information Nacility Name: USA 68153 Bldg,No_: Site Address: 2448 W. Kettleman Ln. 2 Lower Sacramento City: Lodi, CA Zip: 95242 Facility Contact Person: ' Contact Phone No.: (2091369-3124, Make/Model of Monitoring Systent: Gil EMC Date of Testing Servicing R7 B. Inventory of Equiprnent Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced; Tank II)• _ Tank I1)• ❑ ail.Tank Gauging Probe. Model; ❑ In-Tank Ciaugin_v,Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model; ❑ Piping Sump\Trurich Sensor(s). Model: ❑ Piping Suntp\ I rench Sensor(s). Model' ❑�v[,Tl I Sump Sensor(s). Model: E] Fill Sump Scnsor(s). Model: N3- echanical Line l..cak Detector. Model: � ❑ Mechanical Linc l.cik nctcctor. Model: ❑ Electronic l.,inc Lcak Detector. Model: EI Electronic Lille Leak Detector. Model: ❑ Tank Overfill\High-Lcvcl Sensor. Model: ❑ Tank Overfill\l ligh•Level Sensor, Model: ❑ Other(specify equipment tylx:and model in Section C on Page 21l. ❑ Othcr(specify equipment type and model In Section F on Page 2)_ Tank IU- "Tank ID- Ill.Tank Gauging Probe. Model; ❑ in-'lank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space of Vault Sensor. Model: [l Piping Sump\Trench Sensor(s). Model: _ ❑ Pilling Sump\Trcnch Sensor(s). Model; ❑ Fill Sump sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector, Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Linc 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 ill Section 1:on Page 2). ❑ Othcr(specify equipment type and model in Section F.on Page 2). Dispenser 1D' Dispenser i% ❑ Dispenser Containment Sensor Is). Model: ❑ I)ispenser Canlainrrtenl Setlsor(s). Model: ❑ Shear Valve(s), ❑ Sllcar Valve(s). p Dispenser Containment Float(s)and Chain W. ❑ Dispenser Containment Float(s)and Chain(s). Dispenser Ill- Dispenser ID• ❑ Dispenser(:ontainmeol Sensor(s). Model: ❑ Dispenser Coillainlncnt Sensor(s). Model: ❑ Shear Valve(S). ❑ Sllcar Valve(s). ❑ Dispenser Cuntainment Float(s)and Chain(s). ❑ Dispenser Containment float(s)and Clridrl(s). Dispenser I . Dispenser IP- Containment Sensor W. Model: ❑ Dispenser Conl:unmenl Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Corltainrncnt Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form.lilclude inforntatirnt for every tank and dispenser at the facility C. Certlflcation - I certify that the equipment identified in thio document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to lois Certification is information(e.g. manufactures'checklists)necessary to verity that this information Lc correct and it Plot Plan showinu Clic layout of monitoring;equipment. For any equipment capable of generating such reports,1 have also attached a copy of the; (check all that apply). ❑ System set-up ❑ MUM histor rep rt Technician Name(print): Randy A Wilkerson Signature: Mfg. Cert.#.: Z`o iCC# 5258560-UT License.No.: 485184 Testing Company Narne: Serv. Sta. SYS. Phone No.: 408 971-2445 Site Address: 2448 W. Kettleman Ln.@ Lower Sacramento Date of Testing/Servicing: 07