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MONITORING SYSTEM CERTIFICATION 4M® For Use By All Jurisdictions Within the State of Calofmia Authority AChapter 6.7, Health and Safety Code; Chapter 16, Division 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 insalled at the facility, a separate certification or report must be prepared for each monitring 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 onn tot a local agency regulating UST systems within 30 days of test date. Instructions are printed on the back page. A. General Information Facility Name: KISHIDA TRUCKING Site Address: 1725 ACKERMAN DR Facilty Contact Person: MANAGER Make/Model of Monitoring System: ofnniteC 80002 B.Inventory of Equipment Tested/Certified City: LODI Contact Phone No: 368-0603 Date of Testing/Service: 03/21/2001 Word Order Number: 2216061 Check the appropriate boxes to Indicate specific equipment inspected/serviced CA Zip: 95240 Tank ID: 1 1 Tank ID: 1 1 In -Tank Gauging Probe. Annular Space or Vault Sensor. Piping Sump/Trench Sensor(s). Fill Sump Sensor(s). Mechanical Line Leak Detector. Electronic Line Leak Detector. Tank Overfill/High-Level Sensor. Dispenser Containment Sensor(s) Shear Valve(s). Model: 80002 Model: 80002 Model: 80002 Model: Model: FX1 DV 4358 Model: Model: 80002 Model: Dispenser Containment Float(s) and Chains(s). Other(specify equipment type and model in Section E on page 2). In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 80002 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 4942 Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: 80002 Dispenser Containment Sensor(s) Model: Shear Valve(s). Model: Dispenser Containment Float(s) and Chains(s). Other(specify equipment type and model in Section E on page 2). In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 7Annular 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: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chains(s). Dispenser Containment Float(s) and Chains(s). Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). C. Certification 1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this certificafion is information (e.g manufacturer's 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: MATT SIGNATURE: A4 COMPANY: Tanknology PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 05/00