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r N` Appendix V! MONITORING SYSTEM CERT MAR 3 0 2010 Authority Cited: Chapter 6.7, Health and rSafe Use y Clode; Chtapter 16,ions Division 3,the Stat ��HEALTH I Regulations fn isode of This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared far each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system ownerloperator 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 Kl.—.. AIG SPANOS JET CENTER Site Addragc 4800 S AIRPORT AVEV Bldg.NO,: Facility Contact City: STOCKTON CA Pp.mnn- THOMAS zip: 95206 Make/Model of Monitoring System: VEEDER ROOT_ TLS 350 Contact Phone No.: L209)982-1550 ~ B. Inventory of Equipment Tested/Certified Date of Testing/Servicing: 2126/2010 _ Check the appropriate boxes to indicate specific equi ment inspectediserviced: Tank ID: JET 1 _ ® In-Tank Gauging Probe. Model: MAGI Tank ID: JET 2 k Gauging Probe. 1.1Annular Space ar Vault Sensor. Model: 420 21 In-TanModel MAG 1 ® Piping Sump/Trench Sensor(s). Model 208 0 Annular Space or Vault Sensor. Model 409-- ❑ Fill Sump Sensor(s) ® Piping Sump/Trench Sensor(s). -- Model: ❑ Fill Sump Sensor(s). Model. 208 ® Mechanical Line Leak Detector, Model: FXIV 8 Model: ❑ Electronic Line Leak Detector, Model: Mechanical Line Leak Detector. Model: FXIV D 0 Tank Overfill/High-Level Sensor Model: ❑ Electronic Line Leak Detector. Model: Q Other(specify equipment type and model in Section E on Page 2). ❑ Tank Overfill/High-Level Sensor. Model: ~~�� ❑ Other(specify Tank ID: JET 3 equipment type and model in Section E on Page 2) ® In-Tank Gauging Probe. Tank 1D: Model: MAG 1 Q Annular Space or Vault Sensor, Modol: 409 11In-Tank Gauging Probe. Model: 2 Piping Sump 1 Trench Sensor( ). Model: ?fl8 s ED Ann ular Space or Vault Sensor. Model: ❑ Fill Sump Sensor(s), Model: ElPiping Sump/Trench Sensor(s). Model: ® Mechanical Line Leak Detector, Model: VAFOELESS HIGH FLOW ❑ FII Sump Sensor(s). Model: ❑ Electronic Line Leak Detector. Q Mechanical Line Leak Detector, Model: Model: ElTank Overfill/Nigh-Level Sensor. Model: El Electronic Line Leak Detector. Model: C1Other(specify equipment type and model in Section E on Page 2). ❑ Tank Overfill!High-Level Sensor. Model: Dispenser ID: AV GAS TRANS SUMP ID Other(specify equipment type and model in Section E on Page 2). Q Dispenser Containment Sensor(s) Model: tog Dispenser ID: ❑ Shear Valve(s). ❑ Dispenser Containment Sensor(s)_ Model: ❑ Dispenser Containment Float(s)and Chain(s). Q Shear Valve(s), ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: JET FUEL TRANS SUMP 0 Dispenser Containment Sensor(s) Model 208 Dispenser 0: ❑ Shear Valve(s). ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Floats)and Chain(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s) Dispenser ID: FILL FILTER SUMP Dispenser ID: ❑ Dispenser Containment Sensor(s), Model: 208 ❑ Dispenser Containment ED Shear Valve(s). Sensor($). Model: ❑ Dispenser Containment Float(s)and Chain(s). El Shear Valve(s). 'If the facility contains more tanks or dispensers,copy this form. Include information for earyDtapk and d Spenser enser Containment ht Floats}and Chain(s). t e 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 t COPY of the report;(check all rhor rrpplp):he layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a �System set-up ®Alarm history report Technician Name(print): DAVE WINKLER Certification No.: 5263373-UT Signature: S, Testing Company Name AFFORDA-TEST License No: 08-1739 Testing Company Address: 416 2" STREET GALT,CA 95632 Phone No. {2091 744-!)113 Date of Testing/Servicing: Monitoring System Certification Page 1 of 4 2/21/07 �f)