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Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 161, Division 3,Title 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work,A copy of this form must be provided to the tank system ownerloperator.The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A, General Information Facility LATHROP FOOD GAS Bldg.No.: u�m Site Addrnss- 14800 W FRONTAGE RD City: MANTECA CA Zip: Facility Contact JESSIE Contact Phone Na.: ( ) Persnn Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Test ng/Servicing: 1 212 712 011. B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ectedlserviced: Tank ID: 87 Tank ID: 91 ® In-Tank Gauging Probe. Model: MAG 1 0 In-Tank Gauging Probe. Model: MAG 1 • Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor, Model: 407 ® Piping Sump 1 Trench Sensor(s). Model: 208 ED Piping Sump l Trench Sensor(s). Model: 208 El Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 11 Mechanical Line Leak Detector. Model: LD 2000 ® Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill 1 High-Leve;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: DSL Tank ID: • In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Mode;: • Annular Space or Vault Sensor. Mode;: 407 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump l Trench Sensor(s). Model: 208 ❑ Piping Sump 1 Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model. FXIV D ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Mode;: ❑ Electronic Line Leak Detector. Mode;: ❑ Tank Overfill l High-Level Sensor. Model: ❑ Tank Overfill 1 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 10: 5-6 * Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s), El Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s) Dispenser ID: 3-4 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment El Dispenser Containment Sensor(s). Model: Sensor(5). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Cr in(s). ❑ 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 Inspectedlserviced 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 u!/rhar apply): ❑System set-up ❑Alarm history report Technician Name(print): DAVE WINKLER Signature: 14-may--- 7 Certification No.: 5263373-UT License No: 06-1739 Testing Company Name: AFFORIDA-TEST Phone No. 209 744-0113 Testing Company Address: W1_6_2'_'STREET GALT,CA 95632 Date of Testing/Servicing: 12-27-2011 Monitoring System Certification Page 1 of 4 2/21/07