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0 Appendix VI &SCE, MONITORING SYSTEM CERTIFICATION VED 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 Regul 02 2013 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 systems within 30 days of test date. ER ��ER�_6ZAL T A. General Information 11 Facility Name: LODI MEMORIAL HOSPITAL Bldg.No.: Site Address: 978 FAIRMONT City: LODI Zip: Facility Contact Person: RANDY Contact Phone No.: L-209)3397667 Make/Model of Monitoring System: AUTO STIK Date of Testing/Servicing: 10-09-13 B. Inventory of Equipment Tested/Certified Check-the-appropriate boxes to Indicate sipecific NuIpMent ins cted/serviced: FTankDIESEL Tank ID: Gauging Probe. Model• MAG ❑ In-Tank Gauging Probe. Model: Space or Vault Sensor. Model: LS-3 ❑ Annular Space or Vault Sensor. Model: ump/Trench Sensor(s). Model: LS-3 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ Tank Overfill/High-Level Sensor. Model: r❑ Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: [I In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line 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 in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Senors). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). F[3DWpenser r ID: Dispenser ID: Dispenser Containment Containment Sensor(s). Model: Sensor(s). Model: aive(s). Shear Valve(s). ❑ spenser Containment Float(s)and Chain(s). [3 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 manufacturers' guidelines.Attached to this Certification Is information(e.g.manufacturers'checklists)necessary 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,I have also attached a copy of the report;(check all that apply): N system set-up ®Alarm history report Technician Name(print): FELIX RAMIREZ Signature: ,U.(f Certification No.: 5273934-UT License No: d 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)7440113 — Testing Company Address: 418 2 STREET GALT,CA 95832 Date of Testing/Servicing: 10-09-13 Monitoring System Certification Page 1 of 4 2/21/07