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JUN-26-2009 08:25 Service Station Systems 408 938 8888 P.03 Monitorinoystem Equipment xtification 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 Regulalions This form must be used to document testing and servicing of monitoring equipment. 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 system within 30 days of test date. A. General Information Facility Name: USAITeSoro Bldg.No.: Site Address: 2448 W. Kettleman Ln, @ Lower Sacramento City: Lodi, CA Gip: 95242 Facility Contact Person: Manager Contact Phone No.: (209)369-3124 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 5/27/09 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific cquipmcnt inspected/serviced- Tank Ip:01-Rego Tank ID 02-Plus ❑ In-Tank Gauging Probe. Model: VR 846390-107 q In-Tank Gauging Probe. Model: VR 646390/07 (3 Annular Space or Vault Sensor, Model; VR 79ase0.409 Q( Annular Spacu or Vault Sensor. :Model: VR 794390-409 5 Piping Sump\Trench Sensor(s). Model: VR 794380-208 IN Piping Sump\Trcnch Scnsor(s), Model: VR 794390-205 Q( Fill Sump Sensor(s), Model: VR 794380-208 ❑ Fill Sump Sensor(s). ModelVR 794390-206 (3 Mechanical Linc Leak Detector, Modcl; vaporing&LD2000 a Mechanical Linc Leak Detector. Model: Vaporiess L02000 ❑ Electronic Line Leak Detector, Model; Nana ❑ Hectronic tine Leak Detector. Model: Hone ❑ Tank Overfill\High-Level Sensor, Model; Noon ❑ Tank Overfill\Hi;h-Level Sensor. Model: none ❑ Other(specify equipment type and model in Section E on Page 2), E3 Other(specity equipment type and mcAel in Section 1:on Page 2). Tank ID, 03-Prem Tank 1D: O In-Tank Gauging Probe. Model: VR 846390-107 ❑ In-Tank Gauging Probe, Model: C1 Annular Space or Vault Sensor Nlodcl: VR 794390.409 ❑ Annular Space or Vault Sensor. Model: Piping Sump\Trench Settlor(s). Model VR 794390-205 ❑ Piping Sump\Trench Scnsor(s), Model: CK Fill Sump Scnsor(s). Model: VR 794390-205 ❑ Fill Sump,Scnsor(s). Model: II Mechanical Line Leak Detector, Model; Vap.2deee L02000 ❑ Mechanical Line Teak Detector. Model: ❑ Electronic Line Leak Detector. Model: None ❑ Electronic Linc Leak Detector, Model: L7 Tank 0vcrflll\High-Level Sensor. Model: None ❑ Tank Overfill\High-Level Sensor, Model: Q Other(specify equipment type and model in Section E on Page 2). 0 Other(specifv equipment type and model in Section E on Page 2). Dispenser TD; 01-02 Dispenser ID: 03-04 _ ❑ t)iapenser Containment Sensor(s). Model: None ❑ Dispenser Contaimncnt Sensor(s). Model: Norte m Shear Valve(s) % Shear Valve(s). 13 Dispenser Containment Float(s)and Chain(s). tX Dispenser Containment Float(s)and Chain(s). Dispenser TD: O"rl Dispenser ID: 07-08 —_ ❑ Dispenser Containment Sensor(s). Model: Noon ❑ Dispenser Containment Sensor(s). Model: None [9 Shcar valve(s). IX Shear Valve(s), 13 Dispenser Containment Float(s)and Chain(s). Q( Dispenser Containment Float(s)and Chain(s), Dispenser ID: Dispenser ID;_ L3 Dispenser Containment Sensor(s). Model: E] Dispenser Containmcnt Sensor(s), Model: ❑ 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 cquipmcnt identifccti in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e g.manufactures'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipmeat capable of generating such reports,I have also attached a copy of the; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name(print): Bryan Lundien Signature: Mfg.Cert.#.: B36094 1CC# 8001468•U License.No.: 485184 Testing Company Name: Serv. Sta. Sys. Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave., San Jose CA 95112 Date of Testing/Servicing: 5127/09