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0 Appendix VI r RECEIVED MONITORING SYSTEM CERTIFICATION JAN 1 1 2016 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 C¢ ��fl�gT�ulations This form must be used to document testing and servicing of monitoring equipment AP�pante certification oPreport must bQigprfNgrrHEALTH each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tanks $ldBF 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: LATHROP GAS & FOOD Bldg.No.: Site Address: 140 E. LATHROP RD. City: LATHROP Zip: 95330 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 12/92015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins ectedlserviced: FID: Tank Size: Tank ID: Tank Size: ging Probe. Model: MAG 2 ❑ In-Tank Gauging Probe. Modelce or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: /Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model umpensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector, Model: 99 LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Madel: ❑ 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). Tank ID: DIE Tank Size: Tank ID: 91 Tank Size: ® In-Tank Gauging Probe, Model: MAG 2 E In-Tank Gauging Probe, Model: MAG 2 .. ® Annular Space or Vault Sensor. Model: 420 E Annular Space or Vault Sensor. Model: 420 E Piping Sump/Trench Sensor(s). Model: 2 0 8 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Senso,(s). Model: E Mechanical Line Leak Detector. Model: 99 LD 2000 E Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overall/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 Dispenser ID: 774 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: E Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Floats)and Chain(s). Dispenser ID: 5 / 6 Dispenser ID: 7 / 8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Floats)and Chain(s). Dispenser ID: 9 / 10 Dispenser ID: 11 / 12 ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). E Dispenser Containment Float(s)and Chain(s). E 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-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): ®System set-up E Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A28448 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date of Testing/Serviang: 12/92015 Monitoring System Certification Page 1 of 4 2/21/07 E3 (b LA EN