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Appendix VI JUN i ? 101i MONITORING SYSTEM CERTIFICATION tit. For Use By All Jurisdictions Within the Stale of California Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23,California Code of 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 forth 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 Bldg.No.: Site Address: 76115 AIRPORT WAY Cay: STOCKTON ZJp: 96206 Facility Contact Person: Contact Phone No.: (209)962.1841 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 05-27-11 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins ctedlserviced: 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/Trench Sensor(s). Model: 205 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensoria). 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: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipmenttype and model in Section E on Page 2). ❑ 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/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensoria). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model ❑ Tank Overall I High-Level Sensor. Model: ❑ Tank Overall/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 10: 1-2 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Senors). Model: ® Shear Valye(s). ❑ Shear Valve(s). ® Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensogs). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Floats)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 Floats)and Chain(s), ❑Dispenser Containment Float(s)and Chain(s). 'if the facility contains more tanks or dispensers,copy this forth. Include information for every tank and dispenser at the facility. C.Certification-I certify that the equipment identified 1n this document was inspected/serviced in accordance with the manufacturers- guidelines.Attached to this Certification is information(e.g.manufacturers'check]Ists)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: .11 _ Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 STREET GALT,CA 95632 Date of TestingiServicing: 05-27-11 Monitoring System Certification Page 1 of 4 2/21/07