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Appendix VI RECEIVED MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California AUG 21 2018 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��[[��qq�NMEN TAS each monitoring system control panel by the technician who performs the work.A copy of this forth must be provided to the t�IIk`k owner/operator.The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30"ALTH"EPARTMENT A. General Information ITCH Facility Name: LOVES TRAVEL PLAZA-TRUCK Bldg.No.: Site Address: 1553 COLONY RD City: RIPON Zip: 95366 Facility Contact Person: Niel&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: DIESEL Tank ID: DIESEL N In-Tank Gauging Probe. Model: MAG 3 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 N Mechanical Line Leak Detector. Model: VAPORLESS N Mechanical Line Leak Detector. Model: VAPORLESS ❑ 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: DEF Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: N Piping Sump/Trench Sensogs). Model: 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 ID: 21 DispenserlD: 21S/22 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: 22S/23 Dispenser ID: 23S/24 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). DispenserlD: 24S/25 Dispenser ID: 25S/26 ®Dispenser Containment N Dispenser ContainmentSensor(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 N Alarm history report Technician Name(print): FELIX RAMIREZ Signature: f Certification No.: 8883072-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 4162 nd STREET GALT,CA 95632 Date of Testing/Servicing: 08-09-18 Monitoring System Certification Page 1 of 2/21/07