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0 • RECEIVED Appendix VI MAY 18 2015 MONITORING SYSTEM CERTIFICATION 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 CofffMONMENTAL This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must br41eWT - 9:Ab0T4All 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 ownertoperator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date, A. General Information Facility Name: ESTES EXPRESS Bldg. No.: Site Address: 7611 S AIRPORT WAY Facility Contact Person: JIMMY Make/Model of Monitoring System: VEEDER ROOT TLS 360 City: STOCKTON Zip: 96206 Contact Phone No.: (209) 982.1841 B. Inventory of Equipment Tested/Certified Check the aoorooriate boxes to indicate specific eauiument inspected/serviced: Date of Test nglServiong: 05-15-15 Tank ID: DIESEL_ Tank ID: ® In -Tank Gauging Probe. Model: MAG ❑ In-Tank�Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: 302 _ ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump 1 Trench Sensor(s). Mode[ 206 ❑ 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: ® Tank Overfill / High -Level Sensor. Model, FLAPPER ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Q Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe, Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump 1 Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill 1 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 an Page 2). Dispenser ID: 1-2 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model, ® Shear Valve(s). ❑ Shear Vaive(s). IRi Dispenser Containment Floats) and Cham(s). ❑ Dispenser Containment Float(s) and Chain(s). DispenserIll Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model'. ❑ Shear Valve(s), ❑ Shear Valve(s), I_1 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: 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 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 je.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 Mar apply): ® System set-up E 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 TestinglServicing: 05-15-15 Monitoring System Certification Page 1 of 4 2/21107