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09CERED G� Appendix VI 'I./ FES 1 6 2010 MONITORING SYSTEM CERTIFI(MIMMENTHEALTH For Use By All Jurisdictions Within the State of Califfi�i�11(AITJGGRI/I(�CC* Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title a o l 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 form must be provided to the tank system owner/operator.The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General information Facility RIVER PT MARINA Bldg.No.: Na Site 4950 BUCKLEY COVE WAV City: STOCKTON CA Zip: Art rear' Facility Contact perAnn. RICH Contact Phone No.: (209)957.4144 Make/Model of Monitoring System: RONAN X76S Date of Testing/Servicing: 111512010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific a ui ment Inspected/seryiced: TanklD: 89 Tank ID: RED DSL ❑ In-Tank Gauging Probe. M odel. 7E] ❑ In-Tank Gauging Probe. Mode(: ® Annular Space or Vault Sensor. ® Annular Space or Vault Sensor. Model: LS-3 ® Piping Sump/Trench Sensor(s). ® Piping Sump/Trench Sensor(s). Model: LS-3 ❑ Fill Sump Sensor(s). ❑ FIII Sump Sensor(s). Model. ® Mechanical Line Leak Detector, ® Mechanical Line Leak Detector. Model: STP-MLD ❑ 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). 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/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 Overall/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: RED DSL Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: YES ❑ Dispenser Containment Sensor(s). Model: Cl Shear Valve(s). ❑ Shear Valve(s). ® Dispenser Containment Float(s)and Cham(s). ❑ Dispenser Containment Floats)and Cham(s). Dispenser ID: 89 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: YES _ ❑ Dispenser Containment Sensor(s). 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 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 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): DAVE WINKLER Signature: Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 STREET GALT CA 95632 Dale of Testing/Servicing: 1-15-2010 Monitoring System Certification Page 1 of 4 2/21/07 Cc JLf\