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RECEIVED Appendix VI MONITORING SYSTEM CERTIFICATION AUG 2 y 2M 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,California Cod�eNVll _AL This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must'ba p�p� RTMENT each monitoring system control panel by the technician who performs the work.A copy of this form must be provided kdE l y�A 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: LOVES TRAVEL PLAZA-AUTO Bldg.No.: Site Address: 1553 COLONY RD City: RIPON Zip: 95366 Facility Contact Person: NEIL&JESSE Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 08-09-18 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 Tank ID: 87 R In-Tank Gauging Probe. Model: MAG 1 N In-Tank Gauging Probe. Model: MAG 3 N Annular Space or Vault Sensor. Model: 420 N Annular Space or Vault Sensor. Model: 420 N Piping Sump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 N Fill Sump Sensor(s). Model: 208 N Fill Sump Sensor(s). Model: 208 R Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: N Tank Overfill/High-Level Sensor. Model: FLAPPER N Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ 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: 91 Tank ID: R In-Tank Gauging Probe. Model: MAG3 ❑ In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: N Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: R Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ 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 ID: 1-2 Dispenser ID: 3-4 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 R Shear Vafve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 ®Dispenser Containment N Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 N 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 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 Technician Name(print): FELIX RAMIREZ Signature: Certification No.: 8883072-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date of Testing/Servicing: 08-09-18 Monitoring System Certification Pagel of 2/21/07