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I 1 ,rV lt�1 ii,. Appendix VI2016 MONITORING SYSTEM CERTIFICATION AUG 2 9 For Use By All Jurisdictions Within the State of California �„Pr1Hblly Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulati This form must be used to document testing and servicing of monitoring equipment. 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: LOVES TRAVEL PLAZA - TRUCK Bldg. No.: Site Address: 1553 COLONY RD City: RIPON Zip: 95366 Facility Contact Person: JESSE Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 08-10-16 B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate snerifir PnuinmPnt insnPrtPd/sPrvirPd- Tank ID: DIESEL Tank ID: DIESEL S In -Tank Gauging Probe. Model: MAG 3 S In -Tank Gauging Probe. Model: MAG 3 S Annular Space or Vault Sensor. Model: 420 S Annular Space or Vault Sensor. Model: 420 S Piping Sump / Trench Sensor(s). Model: 208 S Piping Sump/ Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 S Fill Sump Sensor(s). Model: 208 S Mechanical Line Leak Detector. Model: VAPORLESS S Mechanical Line Leak Detector. Model: VAPORLESS ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: S Tank Overfill / High -Level Sensor. Model: FLAPPER S 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). TanklD: DEF TanklD: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: S Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: S Piping Sump / Trench Sensor(s). 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 Dispenser ID: 21S/22 S Dispenser Containment Sensor(s). Model: 208 S Dispenser Containment Sensor(s). Model: 208 S Shear Valve(s). S 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 S Dispenser Containment Sensor(s). Model: 208 S Dispenser Containment Sensor(s). Model: 208 S Shear Valve(s). S Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 24S/25 Dispenser ID: 25S/26 S Dispenser Containment S Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 S Shear Valve(s). S Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). n me racnny contains more ianKS or aispensers, copy iniS corm. mcivae mrormaaon Tor every tanK ano aispenser at the Tacuny. 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): S System set-up S Alarm history report Technician Name (print): FELIX RAMIREZ Signature: Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2"STREET GALT, CA 95632 Date of Testing/Servicing: 08-10-16 Monitoring System Certification Page 1 of 4 2/21/07