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V i.. ., •A� Appendix VI � ' MAY 2 9 2015 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California ENVIRONMENTAL HEALTH Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regalaudw Thls 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 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: ESTES EXPRESS Bidg. No.: Site Address: 7611 S AIRPORT WAY City: STOCKTON Zip: 95206 Facility Contact Person: JIMMY Contact Phone No.: (209) 982-1841 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 05-15-15 B. Inventory of Equipment Tested/Certified Cher -k the annrnnriate hnxes to indirate snerifir enuinmant insnertedlservir-ed: Tank ID: DIESEL Tank ID: Z In -Tank Gauging Probe. Madel: MAG ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 302 ❑ Annular Space or Vault Sensor. Model: Z Piping Sump 1 Trench Sensor(s). Model: 205 ❑ Piping Sump /Trench Sensor(s), Model: ❑ Fill Sump Sensor(s). Model ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: PE PETRO ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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). TanklD: TanklD: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model; ❑ Piping Sump/ Trench Sensor(s). Model: ❑ Piping Sump 1 Trench Sensor(s). 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 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). Dispenser 1D: 1-2 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: DispenserlD: ❑ 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). DispenserlD: Dispenser ID: ❑ Dispenser Containment El Dispenser Containment Sensor(s). Model Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ 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 racily. 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 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 apply): ® System set-up ® Alarm history report Technician Name (print): FELIX RAMIREZ Signature: Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 05-15-15 Monitoring System Certification Page 1 of 2/21/07