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, MONITORING SYSTEM CERTIFICATION JUL 0 5 2016 For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Caldfomia Code of Regulations, ,, This form must be used to document testing and servicing of monitoring equipment. 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. The owner/operator 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: Site Address: Facility Contact Person: VAN De POL - LODI PAC PRIDE Bldg. No.: 351 N. BECKMAN RD. City: LODI Zip: 95240 Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT - TLS -350 Date of Testing/Servicing: 6-24-16 B. Inventory of Equipment Tested/Certified Check the aoaroariate boxes to indicate soec'Ific eauioment inspected/serviced: Tank ID: DSL SLAVE Tank Size: Tank ID: DSL A -B Tank Size: ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 460 ® 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: 208 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: FE PETRO ® Mechanical Line Leak Detector. Model: 99LD2000 FXIV ❑ Electronic Line Leak Detector. Madel: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Leve) 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). Tank ID: RED DSL Tank Size: Tank ID: 91 Tank Size: ® In -Tank Gauging Probe. Model: MAG I ® In -Tank Gauging Probe. Model: MAG I ® Annular Space or Vault Sensor. Model: 420 ® 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: 208 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: FE PETRO ® Mechanical Line Leak Detector. Model: 99LD2000 ❑ 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). Tank ID: 87 Tank Size: Tank ID: Tank Size: ® In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 344 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99LO2000 ❑ 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). Tank ID: Tank Size: Tank ID: Tank Size: ❑ 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 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). C. Certification - I certify that the equipment identified in this document was inspectecilserviced 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): ® System set-up ® Alarm history report ®Inspector has print out. Technician Name (pnrM): David Winkler Signature: Certification No.: B34975 License No: Testing Company Name: AFFORDA-TEST Phone No. (209) 744-W 13 Testing Company Address: 416 2n° STREET GALT, CA 95632 Date of Testing/Ser icing: 6-24-2016