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i RL'Gi Appendix VI SEP 2 7 2016 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California f�'t_kAL HEALTH Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16, Division 3,Title 23,Califor QfyW� !ppp pp7 L This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must lblp pa�irfbd IM EN each monhonng system control panel by the technician who performs the work.A copy of this forth 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: EM11:S LIQUOR & SPORT SHOP Bldg.No.: Site Address: 1405 CALIFORNIA ST. City: ESCALON Zip: 95320 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitonng System: GILBARCO EMC Date of Testing/Servicing: 6/28/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ectedlserviced: Tank ID: 87 Tank Size: I I K Tank ID: Tank Size: N In-Tank Gauging Probe. Model: MAG 2 ❑ In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: N Piping Sump/Trench Sensor(s). Model: 20 8 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ 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). Tank ID: DIE Tank Size: 4 K Tank ID: 91 Tank Size: 5 K N In-Tank Gauging Probe. Model: MAG 2 N In-Tank Gauging Probe. Model: MAG 2 N Annular Space or Vault Sensor. Model: SAME VESSEL N Annular Space or Vault Sensor. Model: SAME VESSEL N Piping Sump/Trench Sensor(s). Model: 20 8 N Piping Sump/Trench Sensor(s). Model: 2 0 8 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sansone). Model: N Mechanical Line Leak Detector. Model: F X-1 V N Mechanical Line Leak Detector. Model: FX-IV ❑ 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: 1 / 2 Dispenser ID: 3 / 4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: N Shear Valve(s). N Shear Velvets). N Dispenser Containment Floats)and Chain(s). N Dispenser Containment Float(s)and Charts). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ 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): N System set-up N Alarm history report Technician Name(print): ZANE NIMMO Signature: '� Certification No.: A28446 License No: 0416766 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company 416 2nO STREET GALT,CA 95632 Date of Testing/Servicing: 6/2812016 Address: Monitoring System Certification Page 1 of 4 2/21/07