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• Appendix VI ORECE V E© FEB 1 6 2010 MONITORING SYSTEM CERTIFICATIONV1RO , EALTH For use By All Jurisdictions Within the State of California Dp��pp�� Authority Cl ed: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, C�1�7t01�� CES This form must a used to document testing and servicing of monitoring equipment. A separate of arathis fo mrtmust'on be or reportvided must be the tank preparedfor each monitoring system control panel by the technician who performs the work. A copy ownerloperator. he ownerloperator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. A. General Facility Na_. Site B. Bldg. No.: City: Zip: CA Facilityontact JAS Contact Phone No.: (209) 369-2790 Per,nn Make/M del of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 1/512010 Tank ID: 87 ® In -Tank Gaugii ® Annular Space ® Piping Sump/ ❑ Fill Sump Sen: El Mechanical Lir ❑ Electronic Line ❑ Tank Overfill / ❑ Other (specify TanklD: DIE ® In -Tank Gaug' ® Annular Spaci ® Piping Sump I ❑ Fill Sump Sen ® Mechanical Li ❑ Electronic Lin ❑ Tank Overfill ❑ Other (specif) of Equipment Tested/Certified Probe. Model: MAG 2 r Vault Sensor. Model. ench Sensor(s). Model: 208 '(s). Model: Leak Detector. Model. ask Detector. Model: gh-Level Sensor. Model: iuioment type and model in Section E on Page 2) g Probe. Model: MAG 2 or Vault Sensor. Model: french Sensor(s). Model: 208 arts). Model. e Leak Detector. Model. Leak Detector. Model: High -Level Sensor. Model: eauioment type and model in Section E on Page 2) Tank ID: 100 OCT ® In -Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model. ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) Tank ID: 91 Dispenser lD: 314 ® In -Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: ® Piping Sump/ Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model. ® Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser lD: 314 Dispenser ID: 112 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Co tainment Sensor(s). Model: 208 ®Shear Valve(s). ® Shear Valve( ). ❑Dispenser Containment Float(s) and Chain(s). ❑Dispenser Containment Floal(s) and Chain(s). Dispenser ID: 7/8 Dispenser ID: SM ®Dispenser Containment Sensor(s). Model: _206 _;;;; ® Dispenser C ntainment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve( ). Dispenser Containment Floats) and Chain(s). _ ❑ Dispenser Containment Floats) antl Chain(s). Dispenser ID: Dispenser ID: 9/10 ❑ Dispenser Containment ® Dispenser Containment Sensor(s). Model: Sensor(s). Model: 208 ❑ Shear Valve(s). ® Shear valve( ). ❑Dispenser Containment Float(s) and Chain(s). _ ❑ Dispenser C Containment Float(s) and Chairi tains more tanks or dispensers, copy this form. Include information for every tank antl dispenser at the facility. 'If the facility co C. Certification - certify that the equipment identified In this document was inspectedlserviced in accordance with the manufacturers' checklists) necessary to verify that this information is correct guidelines. At ached to this Certification is Information (e.g. manufacturers' layout of monitoring equipment. For equipment capablegenerating such reports, I have also attached a and a Plot Pla copy of the re i showing the larm report ort; (check all that apply): ® Y setup Technician Na ne (print): ZANE NIMMO Signature: Certification N .: A28446 License No: 04-1676 Phone 744-0113 Testing Comp Testing Comp ny Name: AFFORDA-TEST Te my Address: 418 2 STREET GALT CA 95632 Date of Testing/Servicing: 01/05/10 _ 2/21/07 Monitoring S stem Certification Page 1 of 4 a3L 0