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Appendix VI C FV EE D MONITORING SYSTEM CERTIFICATION PF(" `, 7 2017 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 Regulations ENVIRONMENTAL HEALTH This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared WDEPARTMENT each monitoring system control panel by the technician who perfomis 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 lrrfonnation Facility Name: LATHROP FOOD AND GAS Bldg.No.: Site Address: 140 E LATHROP RD City: LATHROP Zip: 96330 Facility Contact Person: JESSIE Contact Phone No.: (209)814-3730 Make/Model of Monitoring System: VEEDER ROOT TLS 360 Date of Testing/Servicing: 12-11-17 B. Inventory of Equipment TestedlCedified Check the appropriate boxes to indicatespecific equipment ins ectedlserviced: TanklD: 87 TanklD: 91 S In-Tank Gauging Probe. Model: MAG 1 S In-Tank Gauging Probe. Model: MAG 1 ❑ Annular Space or Vault Sensor. Model: 420 S Annular Space or Vault Sensor. Model: 420 S Piping Sump/Trench Sensor(s). Model: 208 S Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensoria). Model: S Mechanical Line Leak Detector. Model: 90 LD 2000 S Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill/High-Level Sensor. Model: FLAPPER S Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ Other(specify equipment type and model in Section E on Page 2). Cl Other(specify equipment type and model in Section E on Page 2). Tank ID: DIESEL TanklD: S In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: S Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: S Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Senwgs). Model: ❑ Fill Sump Sensor(s). Model: S Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: S Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ 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: 3.4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: S Shear Valve(s). S Shear Valve(s). S Dispenser Containment Float(s)and Chain(s). S Dispenser Containment Float(s)and Chain(s). DlspenserlD: 5-6 DispenserlD: 7.8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: S Shear Valve(s). S Shear Valve(s). S Dispenser Containment Floats)and Chain(s). 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: ® Shear Valve(s). S Shear Valve(s). ® Dispenser Containment Floats)and Chain(s). S Dispenser Containment Float(s)and Chain(s). `If the facility contains more tanks or dispensers,copy this forth. 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 ®Alarm history report Technician Name(print): FELIX RAMIREZ Signature: �y— tm - Cercation No.: 5273934-UT License No: A 0&1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2n0 STREET GALT CA 95632 Date or Testing/Servicing: 12-11-17 Monitoring System Certification Page 1 of 4 2/21/07