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Appendix VI fqhGbVft� MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California��•A C 016 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Re �sD This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the I y �� owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days oftaN,ri�� A. General Information Facility Name: LOVES TRAVEL PLAZA - TRUCK Site Address: 1553 COLONY RD Facility Contact Person: JESSE Make/Model of Monitoring System: VEEDER ROOT TLS 350 Bldg. No.: City: RIPON Zip 95366 Contact Phone No.: B. Inventory of Equipment Tested/Certified Check the annronriate hoxes to indicate snecific eauinment insnected/serviced: Date of Testing/Servicing: 08-10-16 Tank ID: DIESEL Signature: "r' Certification No.: 5273934 -UT Tank ID: DIESEL Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 ® In -Tank Gauging Probe. Model: MAG 3 ® In -Tank Gauging Probe. Model: MAG 3 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump /Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: VAPORLESS ® Mechanical Line Leak Detector. Model: VAPORLESS ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ® 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: ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ® 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 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Vaive(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 22S/23 Dispenser ID: 23S/24 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(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 ® Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 ® Shearvalve(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 torn. Include mtormation for every tank ana aispenser at me Tacuay. 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, 1 have also attached a copy of the report; (check all that apply): ® System set-up ® Alarm history report Technician Name (print): FELIX RAMIREZ Signature: "r' Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2ndSTREET GALT, CA 95632 Date of Testing/Servicing: 08-10-16 Monitoring System Certification Page 1 of 4 2/21/07