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MONITISRING SYSTEM CERTIOCATION <br />CERTIFICATION / TEST DATE: October 28. 2013 <br />Al. FACILITY A2. OWNER <br />Name Countryside 76 Name Rupinder Padda <br />Address 14971 N. Highway 88, Lodi, CA 95240 Address 18662 North Hwy 88, Lockeford, CA 95237 <br />Phone # 209-368-5380 Phone # 209-727-3064 <br />Contact Rupinder Padda Contact Rupinder Padda <br />F. IN -TANK GAUGING / SIR EQUIPMENT: ■ Check this box if tank gauging is used only for inventory control. <br />❑ Check this box if no tank gauging or SIR equipment Is Installed. <br />This section must be completed if in -tank gaugung equipment is used to perform leak detection monitoring. <br />Complete the following checklist: <br />❑ <br />Yes <br />❑ <br />No* <br />Has all input wiring been inspected for proper entry and termination, including testing for ground faults? <br />❑ <br />Yes <br />❑ <br />No* <br />Were all tank gauging probes visually Inspected for damage and residue buildup? <br />❑ <br />Yes <br />❑ <br />No* <br />Was accuracy of system product level readings tested? <br />❑ <br />Yes <br />❑ <br />No* <br />Was accuracy of system water level readings tested? <br />❑ <br />Yes <br />❑ <br />No* <br />Were all probes reinstalled properly? <br />❑ <br />Yes <br />❑ <br />No* <br />Were all Items on the equipment manufacturer's maintenance checklist completed? <br />" In Section H below, describe how and when these deficiencies were or will be corrected. <br />Page 3 of 3 <br />Were all Items on the equipment manufacturer's maintenance checklist completed? <br />" In Section H below, describe how and when these deficiencies were or will be corrected. <br />Page 3 of 3 <br />