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JULRECEIVED 0 0 8 202 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California ENVISW WROI pter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations 1' to document testing and servicing of monitoring equipment. A separate certification or report must be prepated.for 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. Facility Name: LODI PAC PRIDE Address: 351 N BECKMAN LODI CA Facility Contact Person: TED 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 aEEroerlate boxes to indicates ecific equip mant Inspected/serviced: Tank ID: DSL I Tank Size: Tank ID: DSL 2 Tank Size: ® In -Tank Gauging Probe. 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 tr, , ® Mechanical Line Leak Detector. Model: FXIV ® 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: RED DSL Tank Size: Tank ID: 91 Tank Size: ® In -Tank Gauging Probe. 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: FE PETRO 0 Mechanical Line Leak Detector. Model: FE PETRO CI 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 Pgd 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: 99LD 2000 ❑ 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. _R,...: Technician Name (print): David Winkler Signature: V� Certification No.: B34975 License No: Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 STREET GALT, CA 95632 - Date of Testing/Servicing: 6-25-2012