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MONITORING SYSTEM CERTIFICATION d'`� r Use By All Jurisdictions Within the State of Calif , a Authority Cited: Chapter 6. lth and Safety Code; Chapter 16, Division 3 Title*a1ifornia, 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. I he 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 Site Address: 401 W. KETTLEMAN LN Facility Contact Person: MANAGER Make/Model of Monitoring System: VR TLS 350 B. Inventory of Equipment Tested/Certified City: LODI CA Zip: 95240 Contact Phone No:368-8786 Date of Testing/Service: 11/05/2002 Work Order Number: 2224280 Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: REG Tank ID: PREMIUM In -Tank Gauging Probe. Model: MAG 71 In -Tank Gauging Probe. Model: MAG 71 Annular Space or Vault Sensor. Model: 420 X Annular Space or Vault Sensor. Model: 420 Piping Sump/Trench Sensor(s). Model: 208 %( Piping Sump/Trench Sensor(s). Model: 208 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). an an In -Tank Gauging Probe. Model: 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 Sensogs). 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). 01spenSel 10, 172 Ispenser Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: ® ShearValve(s). ShearValve(s) ® Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser Ispenser . Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ® ShearValve(s). ShearValve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ® ShearValve(s). ShearValve(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). . If the facility contains more tanKS or aispensers, copy inls Corm. mcluae inrormaaon Tor every tanK ana alspenser at me Tacinty. 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 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; F-] Alarm history report /4' '_.' PRINTED NAME:KEVIN MATLOCK SIGNATURE: COMPANY: Tanknology PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 03/01