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Appendix VI , - ECEIVEL, 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 Code of Re 109 2015 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! taritrq�{�[rj /'�NMENTAI. owner/operator . The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days I f C � "rrJ r�CO9OTr tC1'T A. General Information Facility Name: MIRACLE MILE MART Bldg. No.: Site Address: 244 W HARDING City: STOCKTON CA Zip: Facility Contact Person: RAY Contact Phone No.: ( I Make/Model of Monitoring System: VEEDER ROOT TLS 360 Date of Tasting/Servicing: a-26-2014 B. Inventory of Equipment Tested/Certified Check the appropriate ri to indicate specific equipment inspected/serviced: Tank ID: 87 DAVE WINKLER Signature: II'--- Tank ID: 91 License No: 08-1739 ® In -Tank Gauging Probe. Model. MAG 1 0 In -Tank Gauging Probe, Model: MAG 1 ® Annular Space or Vault Sensor. Model: 407 0 Annular Space or Vault Sensor. Model: 407 ® Piping Sump / Trench Sensors), Model: 208 0 Piping Sump / Trench Sensors). Model: 208 ❑ Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Motley. ® Mechanical Line Leak Detector. Model: 99LD2000 ® Mechanical Line Leak Detector. Model: FE PETRO ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: 0 Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). 0 Other (specify equipment type and model in Section E on Page 2). TanklD: TanklD: NA ® In -Tank Gauging Probe. Model: 0 In -Tank Gauging Probe. Model'. 0 Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sansone). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensors)_ Model: ® Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model : 0 Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model : 0 Tank Overfill / High -Level Sensor. Model: 0 Other (specify equipment type and model in Section E on Page 2). 0 Other (specify equipment type and model in Section E on Page 2). DlspenserlD: 1.2 DispenserlD: 5-6 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model : 208 ® Shear Velvets), ® Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). DispenserlD: 3-4 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Velvets). 0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chemist Dispenser ID: DlspenserlD: ❑ Dispenser Containment 0 Dispenser Containment Sensor(s). Model: Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). 'If Me 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): ID System set-up 0 Alarm history report Technician Name (print): DAVE WINKLER Signature: II'--- 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 Date of Testing/Servicing: 8-26-2014 Monitoring System Certification Page 1 of 4 2/21/07