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RECEIVED Appendix VI FEB 0 6 2015 MONITORING SYSTEM CERTIFICATION 0� For Use By All Jurisdictions Within the State o1 California IA®NM ENW. Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16,Division 3,Title 23,California Code� � This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be pre Daredfor each monitoring system wntrol 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 forth to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: RIVER POINT LANDING Bldg.No.: Site Address: 4950 BUCKLEY COVE WAY city: STOCKTON, CA Zip: 95219 Facility Contact Person: ANDREW Contact Phone No.: (209) 951-4144 MakeiModel of Monitoring System: RONAN X76 S Date of Testing/Servicing: 1/2111016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment ins ected/serviced: Tank ID: 89 Tank ID: RED DIESEL ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: LS-3 ® Annular Space or Vault Sensor. Model: LS-3 ® Piping Sump/Trench Sensor(s). Model: LS-3 ® Piping Sump/Trench Sensor(s). Model: LS-3 ❑ Fill Sump Sensons). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: STP-MLD ® Mechanical Line Leak Detector. Model: STP-MLD-D ❑ 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(st 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. Madel ❑ Electronic Line Leak Detector. Madel: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Omer(specity equipment type and model in Section E on Page 2). Dispenser ID: 1 / 2 Dispenser ID: 3 / 4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensoria). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Floats)and Chain(s). ® Dispenser Containment Floats)and Chain(s). Dispenser ID: DispenserlD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensorts). Model: ❑ ShearValve(s). ❑ Shear Velvets). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Cham(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shearvalve(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 form. Include Information for every tank and dispenser at the facility. C.Certification-1 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 monhoring 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): ZANE NIMMO Signature: Y` _ Certification No.: 5263327-UT CA UTT2206 Nevada UST26755 Oregon License No 04-1676 CA 2206 Nevada 26755 Oregon Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2m STREET GALT,CA 95632 Data of Testing/Servicing: 1/21/15 Monitoring System Certification Page 1 of 4 2/21/07