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SM Appendix VI MONITORING SYSTEM CERTIFICATION MAR 212014`t� 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,CalifornitRQ",tegulatipS�TM W11t POV--�r�' S This form must be used to document testing and servicing of monitoring equipment.A separate certification or report mCeach monitoring system control panel by the technician who performs the work.A copy of this form must be provided towner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 da A. General Information Facility Name: A,G SPANOS JET CENTER Bldg.No.: Site Address: 4800 S AIRPORT AVEV City: STOCKTON CA Zip: 95206 Facility Contact Person: THOMAS Contact Phone No.: (209)982-1550 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 2-25.2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Ins ectad/serviced: Tank ID: JET 1 Tank ID: JET 2 ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FXIV D ® Mechanical Line Leak Detector. Model: FXIV D ❑ 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). TanklD: JET 3 Tank ID: ® In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ® 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: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD 3000 HIGH FLOW ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overall/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). w Dispenser ID: AV GAS TRANS SUMP Dispenser ID: ® Dispenser Containment Sensor(s). Model: 206 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Velvets), ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: JET FUEL TRANS SUMP Dispenser ID: ® Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Velvets). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: FILL FILTER SUMP Dispenser ID: ❑ Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chaints). ❑ Dispenser Containment Float(s)and Chairl 'If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C.Certification-1 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;(clseck all that apply): ❑System set-up ❑Alarm history report Technician Name(print): DAVE WINKLER Signature: Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)7440113 Testing Company Address: 416 2 STREET GALT,CA 95532 Date of Testing/Servicing: 2-25-14 Monitoring System Certification Page 1 of 4 2/21/07