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Appendix VI MONITORING SYSTEM CERTIFICATION . _ �y 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 Code of�l tc This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for AUG,i1 {016 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 - AUTO Bldg. No.: ��XVrC=I�RfNdr Site Address: 1553 COLONY RD City: RIPON Zip: 96366 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 appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tank ID: 87 Z In -Tank Gauging Probe. Model: MAG 1 E In -Tank Gauging Probe. Model: MAG 3 ® Annular Space or Vault Sensor. Model: 420 Z Annular Space or Vault Sensor. Model: 420 Z Piping Sump/ Trench Sensor(s). Model: 208 E Piping Sump/ Trench Sensor(s). Model: 208 Z Fill Sump Sensor(s). Model: 208 Z Fill Sump Sensor(s). Model: 208 Z Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: E 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: 91 Tank ID: ❑ In -Tank Gauging Probe. Model: E In -Tank Gauging Probe. Model: MAG3 Z Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: E Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z 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 Z Dispenser Containment Sensor(s). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z 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 E Dispenser Containment Sensor(s). Model: 208 E Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z 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 E Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 E 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): E System set-up Z Alarm history report Technician Name (print): FELIX RAMIREZ Signature: fIr 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