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7;nrwrnrocoor-w®l MONITORING SYSTEM CERTIFICATION se By All Jurisdictions Within the State of Califo Authority Cited: Chapter 6.7, hMIth and Safety Code; Chapter 16, Division 3 Title 23, 1111fornia 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 installed at the facility, 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: COUNTRY SIDE MINI MART Site Address: 14971 N HWY 88 Facility Contact Person: GARY BURGIN Make/Model of Monitoring System: VEEDER ROOT B. Inventory of Equipment Tested/Certified City: LODI Contact Phone No: 368-5380 Date of Testing/Service: 10/13/2003 Work Order Number: 2228759 Check the appropriate boxes to indicate specific equipment inspected/serviced CA Zip: 95240 Tank ID: 1 Tank ID: 2 %< In -Tank Gauging Probe. Model: MAGPROBE 71 In -Tank Gauging Probe. Model: MAGPROBE 71 Annular Space or Vault Sensor. Model: 794390-420 X1 Annular Space or Vault Sensor. Model: 79430-420 X Piping Sump/Trench Sensor(s). Model: 794380-208 Piping SumpfT'rench Sensor(s). Model: 794380-208 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). Tank ID: 3 Tank ID: X In -Tank Gauging Probe. Model: MAGPROBE In -Tank Gauging Probe. Model: --1 Annular Space or Vault Sensor. Model: 79430-420 Annular Space or Vault Sensor. Model: X Piping Sumprrrench Sensor(s). Model: 794380-208 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). Dispenser : 1/2 Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: X❑ Shear Valve(s). Shear Valve(s) MDispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3/4 Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). )( Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser lD: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). ❑ 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 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:RAYMOND SIMMS SIGNATURE: COMPANY: Tanknology PHONE NO: (800) 800-4633 page 1 of 3 Based on CA form dated 03/01