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Appendix VI MONITORING SYSTEM CERTIFICATION APR 15 2016 For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,This 23,California Code of Regulations y y�ry, ,.:� y .�41111 This roan must be used to document testing and servicing of monitoring equipment.A separate certication or report must bepiepat r••�•• -• " each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the t3hKirystenl 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: Woodbridge Am Pm Bldg.No.: Site Address: 18806 LOWER SACRAMENTO City: WOODBRIDGE CA Zip: 95268 Facility Contact Person: JAS Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 4-11-2018 B. Inventory of Equipment Tested/Certified Cheek the appropriate boxes to indicatespecific equipment ins ectecilserviced: Tank ID: 87 OCT Tank ID: DSL ® In-Tank Gauging Probe. Model: MAG 7 ® 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 Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FxIV ® Mechanical Line Leak Detector. Model: FE-PETRO-D ❑ 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). Tank ID: 91 OCT Tank ID: NA ® In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 407 ❑ Annular Space or Vault Sensor. Model'. ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD 2000 ❑ 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: ❑ Omer(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: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chalri DispenserlD: 5-6 DispenserlD: 7.8 ® Dispenser Containment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ShearVali ❑ Dispenser Containment Flmgs)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and ChaiO(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 Pian 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(prin0: DAVEWINKLER Signature: g—ol,__) Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 418 STREET GALT,CA 95632 Date of Testing/Servicing: 4-11-2016 Monitoring System Certification Page 1 of 4 2/21/07