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Appendix VI MONITORING SYSTEM CERTIFICATION MAY 2 7 2016 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, California Code of'R 't l{1aallit,pr This form must be used to document testing and servicing of monitoring equipment. A separate certification or reportmust 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 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: ESTE'S FREIGHT -STOCKTON Bldg. No.: Site Address: 7611 AIRPORT BLVD City: STOCKTON Zip: 95206 Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT TLS -350 Date of Testing/Servicing: 5/20/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inenprted/sprvirad- Tank ID: DIESEL Tank Size: Tank ID: Tank Size: M In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 302 ❑ Annular Space or Vault Sensor. Model' IS Piping Sump / Trench Sensor(s). Model: 2 0 8 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: A Mechanical Line Leak Detector. Model: STP -MLD - D ❑ Mechanical Line Leak Detector. Model: El 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: Tank Size: Tank ID: Tank Size: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space cr Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensoria). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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). 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 Sensogs). 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: ❑ Shearvalve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). n me racnny comains more ranks or cispensers, copy this form. Include information for every tank and dispenser at the facility. C. CerOncation -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 Omr apply): ® System set-up ® Alarm history report Technician Name (print): ZANE NIMMO Signature: Certification No.: A2a446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2 STREET GALT, CA 95632 Date of Testing/Servicing: 5/202016 Monitoring System Certification Page 1 of 4 2/21/07