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Appendix VI RECEIVED NIAR 2 8 2011 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California ��NTAL HEALTH Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23, CaliforRA V"SIT/SERVICES Regulations 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 ownerloperator.The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. Generallnformation Facility N.— A,G SPANOS JET CENTER Bldg.No.: Site ArtrlfP.RF' 4600 S AIRPORT AVEV City; STOCKTON CA Zip: 95206 - - Facility Contact Parcnm THOMAS Contact Phone No.: (209)582.1550 MakelModei of Monitoring System: VEEDER',ROOT TLS 350 Date of Testing/Servicing: 212 312 01 1 B. inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins ectedlserviced; Tank ID: JET 1 Tank ID: JET 2 ® In-Tank Gauging Probe. Model: MAG 1 Z In-Tank Gauging Probe. Model: MAG 1 0 Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump l Trench Sensor(s). Model: 208 ® Piping Sump l Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FXIV D 0 Mechanical Line Leak Detector. Model: FXIV D ❑ Electronic Line Leak Detector. Model ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill 1 High-Level Sensor. Model: ❑ Tank Overfill I 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: 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 1 Trench Sensor(s). Model: 208 ❑ Piping Sump 1 Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z 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 Overfill 1 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: AV GAS TRANS SUMP Dispenser ID: ® Dispenser Containment Sensor(s). Model 208 ❑ Dispenser Containment Sensor(s). Model C] Shear Valve(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 ID: ® Dispenser Containment Sensor(s). Model: 208 © 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: FILL.FILTER SUMP Dispenser ID; ❑ Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: El Shear Valve(s). ❑ Shear Valveli ❑ 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 Inspectedlserviced 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 app(e): ❑System set-up ❑Alarm history report Technician Name(print): DAVE WINKLER Signature: -_e J Certification No.: 52663373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. 209 744.01 13 Testing Company Address: 416 2" STREET GALT,CA 95632 Date of Testing/Servicing: 2-23-11 _ Monitoring System Certification Page 1 of 4 2121107 3j C_