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iTOR�NG SYSTEM CIERTIFICA N or Use By All Jurisdictions Within the State of Califo 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 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 LODI PAC PRIDE Facility Contact Person: 351 N BECKMAN LODI CA Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 6/25/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauipment inspected/serviced: Tank ID: DSL 1 Tank Size: Tank ID: DSL 2 ® In -Tank Gauging Probe. Tank Size: Model: MAG 1 ® In -Tank Gauging Probe, Model: MAG 1 ® 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: FXIV ® Mechanical Line Leak Detector. Model: FE PETRO FXIV ❑ 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: RED DSL Tank Size: Tank ID: 91 Tank Size: ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG I ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 I@ 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: FE PETRO ❑ 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: 0 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: FXIV ❑ 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 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): ® System set-up ® Alarm history report ®inspector has print out. Technician Name (print): David Winkler Certification No.: B34975 Testing Company Name: AFFORDA•TEST Testing Company Address: 416 2 STREET GALT, CA 95632 Signature: License No: Phone No. (209) 744-0113 Date of Testing/Servicing: 6-28-2013