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0 0 RECEIVED MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California FEB 142014 Authority Cited:Chapter 6.7,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.A separate certification or report must be prepareda L HEALTH system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. TF1f~T4KFftlCES must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: LODI FOOD&LIQUOR County: SAN JOAQUIN Site Address: 1225 W LOCKFORD City: LODI Facility Contact Person: PAL Contact Phone 209-333-1038 Make/Model of Monitoring System: TS1000 Date of Testing/Servicing: 11/20/2013 B. Inventory of Equipment Tested/Certified Tank ID: T1-87 Tank ID: T2-91 Z In-Tank Gauging Probe. Model: EBW Z In-Tank Gauging Probe. Model: EBW Z Annular Space or Vault Sensor. Model: EIS Z Annular Space or Vault Sensor. Model: EIS(SPLIT) Z Piping Sump/Trench Sensor(s). Model: ULS Z Piping Sump/Trench Sensor(s). Model: ULS ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: LD2000 Z Mechanical Line Leak Detector. Model: LD2000 ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model: FLAPPER Z Tank Overfill/High-Level Sensor. Model: FLAPPER ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: T3-DSL Tank ID: Z In-Tank Gauging Probe. Model: EBW ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: EIS(SPLIT) ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: ULS ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: LD2000 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model: FLAPPER ❑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: 1/2 Dispenser ID: 3/4 Z Dispenser Containment Sensor(s). Model: ULS Z Dispenser Containment Sensor(s). Model: ULS Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 Z Dispenser Containment Sensor(s). Model: ULS Z Dispenser Containment Sensor(s). Model: ULS Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)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 Float(s)and Chain(s). Check the appropriate boxes to indicate specific equipment inspected/serviced: 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 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): Z System set-up Z Alarm history report Technician Name(print): KELVIN CRUZ Signature: Certification 2608993701 License No.: 433159 Testing Company Name: B.Z.Service Station Maintenance Phone No.: (916) 371-2380 Site 1041 Triangle Court West Sacramento,CA 95605 Date of Testing/Servicing: 11/20/2013 Monitoring Certification Test Report 1 of 4