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Appendix VI RECEIVE® MONITORING SYSTEM CERTIFICATION JAN 2 6 2011 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 Regulations ENVIRONMENTAL HEALTH PERMIT/SERVICES 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 Bldg. No.: Name: VALLEY SERVICE STATION ARCO Site Zip: 95204 Address: 16 EAST HARDING LANE City: STOCKTON — P Facility Contact Person: ABRAHAM Contact Phone No.: 20( 9) 4E16-9516 Make/Model of Monitoring System: VEERDER ROOT TLS 350 Date of Testing/Servicing: 12-07-10 Inventory of Equipment Tested/Certified 'f'iui meat inspected/serviced: check the appropriate boxes to indicate specs Tank ID: 87 Tank ID: 89 ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 0 Annular Space or Vault Sensor. Model: 409 ® Piping Sump/ Trench Sensor(s). Model: 208 0 Piping Sump / Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 0 Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: CPT Electronic Line Leak Detector. Model: CPT ® Tank Overfill / High -Level Sensor. Model: 90% 0 Tank Overfill / High -Level Sensor. ❑ Other (specify equipment type and model Model: 90% in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: 91 Tank ID: El In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model: MAG 1 Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/ Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: L] Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: CPT ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: 90% ❑ Tank Overfill / High -Level Sensor. ❑ Other (specify equipment type and model 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 _ 0 Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model 208 0 Shear Valve(s). 0 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 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 0 Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9-10 Dispenser ID: ❑ Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: El Shear Valve(s), ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). f a far avary tank and dispenser at the facility. `If the facility contains more tanks or dispensers, copy this form. Include in orm� 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 0 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 2 STREET GALT, CA 95632 Date of Testing/Servicing: 12-07-10 Monitoring System Certification Page 1 of 4 2/21/07