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MAR, 23. 2010 11 : 59AM AC SPANOS JET CTR NO. 751 P. 1 Appendix VI MONITORING SYSTEM CERTIFICATION 1�AR 2 1' 2010 For Use By All Jurladirtions Withln the State of California Authority Cited:Chapter 8.7, Health and Safety code;Chapter 16, Divi-sion 3,Title 23,California Cade of Regulations This form must be used to document testing and Servicing of monitoring equipment,A seporale onrtification or report muat be prepared for each monitoring sysiem control panel by the technician who performs the work.A copy of this form must be provided to the tank system awnerloperator.The owrerloperator must submit a copy of this form to the local agency regulaling UST systems within 30 days of teat date. A. General information Facility A,0 SPANOS JET CENTER Bldg.NO.: AlamA _ Site AtlNraaa• 4800 S AIRPORT AVEV City: STOCKTON GA Zip: 05200 Pmr. Facility Contact Pnrenrc THOMAS Contact phone No,: (209)982.1550 _...__ Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of TestinglServicing: 212612010 D, Inventory of Equipment TestedlCertfled Check the appropriate boxes to indicatespecific p ut !Hent Ins ectedlservicedt I Tank ID JET 1 Tank ID: JET 2 M In-Tank Gauging Prphe. Madel; MAO 1 � E in-Tank Gauging Probe Madel: MAO 1 ® Annular Simco or Vault Sensor. Modm: 420 ® Annular Space or Vault Sensor. Model: 409 i ® Piping Sump 1 Trench Sensor(s). Model: 206 (M Piping Sump 1 Trench Sensor(s). Modet: 206 ❑ Fill sump Sensor(s). Model: ❑ Fill Sump Sansor(6). Model: IED Mechanical Line Leak Detector. Model: FXIV D ® Mechanical Line Leak Deteolor• Model: FXIV 0 71 Eleclronic fine Leak Detector. Model: ❑ Electronic Lino Leak Detector. Model: Q Tank Overfill f High-Level Sensor. Model; ❑ Tank Overfill I High-Level Sensor. Model; _ Q Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equ'rpmenl type and model in Section E on Page 2). Tank 10; JET 3 Tank IDT i❑c In-Tank Gauging probe. Model: MAG 1 C1in Tank Gauging Probe. Model; ;R Annular space or Vault Sensor. ModaC 409 p Annular Bpaae or Vault Sensor. Model: 9 Piping Sump!Trench Sen90gQ- Model 808 ❑ Piping Sump/Trench Sensor(9), Mooel l. I. 0 Fill Sump Sensor(s) Model: B 1`0 Sump Sensors) Model'. [4 MechanicM Line Leak Detector Model: VAPOELESS HIGH FLOW_ 0 Mechanicai Line Leak Detector, Model- FI EieclroNc Line Leak Detector, Model: _ _ ❑ Electronic Line Leak Detector. Model ❑ Tank Overf+ll 1 High•Lavei Sensor. Modal• ❑ Tank Overfill l Nigh-Level Sensor. Model G Other(specify®quipment lype and model in Section E on page 2). ❑ Other(specify egJlpmertt type and model In Section E on Page 2). !Dlspensar ID: AV GA8 7RANS SUMP T , Dispenser ID: _ 2 Dlspensar Containment Sensor(s), Model. 208 8 Dispenser CoMainment Sensor(s). Model: CI Shear Vatve(s). ❑ shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s), ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: JET FUEL TRANS SUMP Dispenser IDi 0 Dispenser Containment Sensor(s). Model; 208 _ _ C� Diapenaer Containment Sonsor(a), Model: 13 ShearValve(9). t,7 Shearvalvct3), ❑ Dispenser Containment Float(a)end Chain(&), ❑ Diapenaer Conlalnment Float(s)and Chain(a) Dispenser In: FILL FILTER SUMP Dispenser ID: ❑ Dispenser Containment Co Dlspensar Containment Sensar(s). Model: 208 Sensor(s). Model: El Shear Valve(s). El Shear Valve(s), I ❑ Dispenser Containment Float(8)and Chaln(s)• ❑Dispenser Containment Float(s)And Chaln(s). 'If the facility contains more tanks or dispensers,copy this form. Include Information for every tank and dlspsnser at the facility. C.Certification-I certify that the equipment identlfied In this document was Inspectsdlservlced In accordance with the manufacturers' guidelines,Attached to this Certification Is Information(e.g,manufacturers'checklists)necassary 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;(0frech all Mal apply): 0 System setup 9 Alarm history report Technician Name(print): DAVE WINKl_ Ft Signature, ��•—_ Certiflcatlon No.: 5263373•UT License No: _08-1739 Testing Company Name: AFFORDA.TEST Phone No. 209 744.0113 _ Tesling Company Address: 416 2'4 8 REE r GAIT,CA 95e32 _ Date of Teatingrservlcing: Monitoring System Certiflcatlon Page 1 of 4 2/21/07