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Feb 0510 03:07p AFFORDA TEST • 2044-0116 p.2 Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Califomia Authority Ci d: Chapter G.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of This form musta used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared fa, each monkodng If "tonin, panel try the technician who performs the work. A copy of this .`arm must be provided to the tank system ovmedoperator. he ownenoperator must submit a copy of Cnis form to the local agency regulating UST systems within 30 days of test date. A. General ) orrnation Facility Namn' TOKAY SHELL Bldg. No.: Site ACdresa 420 W. KETTLEMAN LN. City: LODI Zip: CA Facility, percnn onta d JAS Contact Phone No.: i2. O9) 369.2790 Makelk al of Monitoring System: VEEDER ROOT TLS 350 Date of TestinglServicing: 1(512010 B. Inven'oy of Equipment Tested/Certified Cheek the adpropriate boxes to Indicate se2cific equipment ins is dfserviced: _ Tank ID: B7 Tank ID'. 100 OCT Probe. klooel: MAG 2 0 In -Tank Gauging Probe. Model: MAG 2 ® In -Tank Gaugin ® Annular Space rVatht Sensor. Mode:: ® Annular Space or Vault Senso-. Model. 9 Piping Sump / rench Sensor(s). Model: 208 0 Piping Sump f Tranct Sensof(s). Model: 208 ❑Pill Samp Sen r(s). Model: I C Fill Sump Sensor($). Modd: ® vtaahanigl Jn leak Detector. Model: ® Mechanical Line Leak Detector. Mode]: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ' ❑ Tank Overt ll) IIgh-Level Sensor. Model: ❑ Tank Overfill) Higr-Level Sensor. Model ❑ Other (specity• squ,limeni type and model in Section E on Page 2). ❑ Other (spectVy equipment type and model in Section E on Page 2). _ Tank ID: DIE Tank ID: 91 Probe. Model: MAG 2 ® In -Tank Gauging Probe. Model: MAG 2 ® In-Tark Gauging ® Annular Space or Vault Sensor. Moder. ® Annular Spare cr Vault Sensor. Model ® Piping Sump/i ranch Sensor(s). Madel: 208 21 Piping Sump l Trench Sensor(s). Model: 208 ❑ Fit Sump Ser4or(s). Model, ❑ Fill Sump Sensorial. Mocet: 19 Mechanical Lie Leak Detector. Model: I i7 Mecnanical Ln e Leak Detector. Madel: ❑ e:ectronic Line Leak Detector. Model: 19f ❑ Electronic L ne Leak Detector. Model: ❑ Tank Overfill I High -Level Sensor. Model: 0 Tank Overfill I High -Level Sensor. Model: ❑ Other ;specify equipment type an model in Section E on Page 2). ❑ Other (specify equip.nem type and model in Section E on Page 2) DispenserlD: 112 - DispenserlD: 314 tainment Sens,r(s). Model: 208 ® Dispenser Co ® Dspeiser Containment Senser(s). Mode,: 208 ® Shear Valval . 0 Shear Valve(s). Dispenser Ccnhinment Floal(s) and Chain($). ❑ Dispenser Containment Floats) and Chain(s). 04 Dispenser ID: 5(6 Dispenser ID: 7f8 0 OspeiserC -Z Dispenser Containmert Sensor(s). fdcdel: 208 :ainment Sensor(s). Model: 208 ® Shear Valve( ). ® Shear Velve(s). ❑ Dispenser ntainment Floats) and Chain(s). m ❑ Dispenser Cortainent Floaqs) and Chain(s). DispenserlD: 9110 Dispenser ID: ❑ Dispenser Containment H DisPenserc nta'nment Sensor(s). Model: 208 Sensor(s). Model. (S Shear Valve( ). ❑ Shear Valve(s). ❑ Dispenser C I ntainme'd Floats) and Chain($). ' J Dispenser Containment Float(s) and Chain(s). a! tanks or dspensers. copy this form. Include Information for every tank and dispenser a1 the facility. 'e the fa7(aimre C. Certifithat the equipment identified in this document was lnspecteifserviced in accordance with the manufacturers' guidel this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct antl a g the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the re iort, (reeek 411 reef apply): ® System set-up ® Alarm history report Technician Nana (print): ZANE NIMMO Signature: I� Certification N .: A28z46 License No: 04-1676 - Testing Comp: my Name: AFFORDA-TEST Phone No. (2091744-0113 Testing Comp my A,drese: 4/e2'SREET GALT, CA 95632 _ were of Teetmg/Servicing: OlLosfia Monitoring S fstem Certification Page f of4 2i2l/07