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AUG-28-2007 17:28 Service Station Systems 408 938 8888 P.03 Monitorir. System Equipment "ertification I'or Use By All Jurisdictions Within The State of Caliyornia Authority Cited: Chapter 6.7, Health and Solely Code; Chapter 16, Division 3, Title 23, California Code ofRegulationc This fonts must be used to document testing and servicing of monitoring equipment. A separate certification or report trust be prepared for each monitorinsytgm_c�htrol 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 forni 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_ N I Contact Phone No.: (209) 369-3124 / Make/Model of Monitoring System: 61 EMC Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID ) Tank IDL i3 5 ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model- ❑ Annular Space or Vault Sensor. Modcl: ❑ Annular .Spacc or Vault Sensor. Model-. In Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Scnsor(s), Model; p T. I Sump Sensor(s). Model: [3 Fill Sump Sensor(s). Model. icchanical Line Leak Detector. Model: L.3' z-b-P--v "echanical Linc Leak Detector, Model: E.S' L+►.�_0 ❑ Electronic Linc Leak Detector. Model ❑ Electronic Line Leak Detector. Model; p Tank Overfill\Idigh-Level Sensor, Model: ❑ I-ark Overfill\l-ligh-Level Sensor. Model; ❑ Qthcr(specify equipment type and model in Sechnn E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2), Tank 10:7 Tanlc ID;,_ ❑ In-Tank Gauging Probe- Modcl: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Scnsor(s), Model: p Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Q Fill Sump Sensor(s). Model; 01-ncchanieal Linc Ixak Detector. Model: CS Z cw ❑ ;v[echanicat line l.cak Detector. Model' ❑ Electronic Linc Leak Detector. Model ❑ Electronic Linc Leak Detector. Model. ❑ -I ank Overfill\High-Level Sensor. Model ❑ Tank Overfill\I ligh-Level Sensor. Model; ❑ Other(specify equipment type and model in Section Eon Page 2). ❑ Other(Speen,equipment type and model in Section E on Page 2). Dispenser M. Dispenser JD; ❑ Dispenser Containment Sensor(s). Modcl: ❑ Dispcnser Containment Sensor(s). Model; ❑ Shear Valve(s). ❑ Shear Valve(S). p Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser IDDispenser Ill• ❑ Dispcnser Containment Sensor(s). Model: ❑ Dispcnser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s), ❑ Dispenser Containment Float(s)and Chain(s). ❑ I)ispenser Containment Float(s)and Chain(s). Dispenser ID• Dispenser ID ❑ Dispenser Containment Sensor(s). Model; ❑ 1)ispenser Containment Sensor(s). Model ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). I] Dispenser Containment Float(s)and Chain(s). 'if the facility contains more tanks or dispensers,copy this form.Include information for every lank 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 thin Certification is information(e.g.manufactures'checklists)necessary to verify(hat this information is correct and a Plot Pian 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): p System set-up ❑ A1x histo y r/eyport Technician Name(print): Randy A Wilkerson Signature: u Mfg.Cert.#.: /�j L y o y ICC# 5258560-UT License.No.: 485184 Testing Company Name: SOM. Sta. Sys. _ Phone No.: 408 971-2445 Site Address: 2448 W. Kettleman Ln. @ Lower Sacramento Datc of Testing/Servicing: