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Appendix VI (AECEIVED MONITORING SYSTEM CERTIFICATION AUG 2 4 2015 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 C� This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must b r� WNTAL. each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to theta�i�C Sjrst& TAACkI r 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: Niel&JESSE Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 08-11-15 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: 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 ® Piping Sump/Trench Sensor(s). Model: 208 S 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). Tank ID: 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 Floats)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). ® 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): S System set-up S Alarm history report Technician Name(print): FELIX RAMIREZ Signature: �/, �<7 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: 08-11-15 Monitoring System Certification Page 1 of 4 2/21/07