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a P 7bnkrxWb9yMONITORING SYSTEM CERTIFICATION ForUse By All Jurisdictions Within the State of CaVa Authority Cited:Chapter 6. , Health and Safety Code; Chapter 16. Division 3 Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility,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. a owner operator must submit a copy o t is orm to t e local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: BEACON#67079 City: LODI CA Zip:85240 Site Address: 401 W. KETTLEMAN LN Contact Phone No:368-8786 Facility Contact Person: MANAGER Date of Testing/Service: 11/05/2002 Make/Model of Monitoring System: VR TLS 350 Work Order Number: 2224280 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: REG Tank ID: PREMIUM In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: MAG 71 Annular Space or Vault Sensor. Model: 420 X Annular Space or Vault Sensor. Model: 420 71 Piping Sump/Trench Sensor(s). Model: 208 �( Fill Sump Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: Fill Sump Sensor(s). Model: Electronic Line Leak Detector. Model: Mechanical_H Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). an an In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Annular Space or Vault Sensor. Model: Fill Sump Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Mechanical Line Leak Detector. Model: Fill Sump Sensor(s). Model: Electronic Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Electronic Line Leak Detector. 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). Ispenser 7spenser Containment Sensor(s) Model Dispenser Containment Sensor(s) Valve(s). () Model: Shear Valves) ser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). 3/14Ispenser . ser Containment Sensor(s) Model• Dispenser Containment Sensor(s). Model: Valve(s). ShearValve(s). ser Containment Floats)and Chain(s). Dispenser Containment Float(s)and Chain(s). ID: 5/6Dispenser ID: ser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ® Shear Valve(s). Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). C. Certification ° If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. I certify that the equipment identified in this document was inspected/seryiced 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 Site Plan 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): System set-up report; Alarm history report PRINTED NAME:KEVIN MATLOCK SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01