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RECEIVED Appendix VI SEP 16 2015 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California ��1/}�Qr,��,��,,��NT L HEALTH Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code oFPERMli EgLICES This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared fo'r'/at 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 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: MIIACLE MILE MART Bldg. No.: Site Address: 244 W HARDING City: STOCKTON CA Zip: Facility Contact Person: RAY Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 8-21-2015 B. Inventory of Equipment Tested/Certified Check Lite appropriate oozes to Indicate s ecmc equipment inspectetl/serviced: Tank ID: 87 Tank ID: 91 ® In -Tank Gauging Probe. Model : MAG 1 ® In -Tank Gauging Probe. Model MAG 1 ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensors) Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99LD2000 2 Mechanical Line Leak Detector. Model: FE PETRO ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Omer (specify equipment type and model in Seceon E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). TanklD: TanklD: NA ® 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 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). Dispenser ID: 1-2 DispenserlD: Dispenser Containment Sensor(s). Model: ® Dispenser Containment Sensor(s). Model: Shear Valve(s). ® Shear Valve(s). X Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3.4 Dispenser ID: Dispenser Containment Sensor(s). Model: ® Dispenser Containment Sensor(s). Model: Shear Valve(s). ® Shear Valve(s). X Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: El Dispenser Containment ElDis Dispenser Containment Sensor(s). Model: PeSensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Cham(s). .......:......_._.__,.__-.:_______ ___....._.___ .__.. ._.., .. ❑ Dispenser Containment Float(s) and Chain(s). .-..^•..••.. .... w� 5 0, u.mpcuxm, copy aria ,mu,. „m,uuc nuum ©uon for every tank and dispenser at me tact ty. C. Certification - I certify that the equipment identified in this document was inspectetl/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.: 5283373 -UT_ License No: 08-1739 _ -- Testing Company Name: AFFORDA-TEST 418 2 STR- Phone No. (209) 744-0113 Testing Company Atltlress: EET GALT CA 95832 Date of Testing/Servicing: 8-21-2015 Monitoring System Certification Page 1 of 4 2/21/07 Isi C