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U 4 Append!XIVI %mRoAmIEW S%SED E �tgtAITJSERVQ%NITORING SYSTEM CERTIFICATION t%F.0 For Use By All Jurisdictions Within the State of California " 0 8 'LULU Authority Cited:Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23,California Co Regulations EigVIFUMENT HEALTH This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be preparedptFRMIT/SERVICES each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank systerA — owner/operator.The owner/operator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. A. General Information Facility Name: LODI PAC PRIDE Bldg.No.: Site Address: 351 N BECKMEN RD City: LODI Zip: 95240 Facility Contact Person: TED Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT TILS 350 Date of Testing/Servicing: 06-25-10 B. Inventory of Equipment Tested/Certified Check thea ropriate boxes to indicates ecific eq ipment ins pectad/serviced: Tank ID: 87 Tank ID: 91 • In-Tank Gauging Probe. Model: MAG 1 0 In-Tank Gauging Probe. Model: MAG I • Annular Space or Vault Sensor. Model: 420 [D Annular Space or Vault Sensor. Model: 420 • Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208 • Fill Sump Sensor(s). Model: 208 0 Fill Sump Sensor(s). Model: 208 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). [1 Other(specify equipment type and model in Section E on Page 2). Tank ID: RED DIE Tank ID: DIESEL/DIESEL 0 In-Tank Gauging Probe. Model: MAG 1 ED In-Tank Gauging Probe. Model: MAG 1 ED Annular Space or Vault Sensor. Model: 420 0 Annular Space or Vault Sensor. Model: 420/420 • Piping Sump I Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208/208 • Fill Sump Sensor(s). Model: 208 1@ Fill Sump Sensor(s). Model: 208/208 E Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: C3 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: [3 Other(specify equipment type and model in Section E on Page 2). [1 Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 E Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 208 Ej Shear Valve(s). 0 Shear Valve(s). El Dispenser Containment Float(s)and Chain(s). [I Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 • Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 208 • Shear Valve(s). 0 Shear Valve(s). 1771 Dispenser Containment Float(s)and Chain(s). [I Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9-10 Dispenser ID: [I Dispenser Containment • Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: • Shear Valve(s). ❑Shear Valve(s). El Dispenser Containment Float(s)and Chain(s). ❑ 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): 0 System set-up [I Alarm history report Technician Name(print): Felix Ramirez Signature: )I Certification No.: 5273934_-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 418 0 STREET GALT,CA 95632 Date of I esting/Servicing: 06-25-10 Monitoring System Certification Page I of 4 2/21/07 C_