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EOuXE5 Appendix VI MAY 11 2016 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California �y a Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16, Division 3,Title 23,California CillAL,��}ROMME M-1�. This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be`p7apaii ,CrAf=hr each monitoring system control panel by the technician who performs 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 information Facility Name: SAVE ON GAS Bldg.No.: Site Address: 420 WEST YOSEMITE City: MANTECA Zip: 95333 Facility Contact Person: Paul Singh Contact Phone No.: (209)267-4400 MakelModel of Monitoring System: VEEDER ROOT 300 C Dale of Testing/Servicing: 4-18-2016 B. Inventory of Equipment Tested/Certified Check t a appropir ate boxes to indicatespecific equipment ins ectecilserviced: TanklD: 87 Tar lD: 91 ® In-Tank Gauging Probe. Model: MAG 0 ® In-Tank Gauging Probe. Model: MAG 0 ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Model: SPLIT W 87 ® Piping Sump I Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sansone). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: PE PETRO ® Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill/High-Level Sensor. Model: FLAPPER ® Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). TanklD: Tari ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump I Trench Sensors). Model: ❑ Fill Sump Sersor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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: ❑ 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 DispenserlD: 3-4 ❑ Dispenser Containment Sensor(s). Madel: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Flaafs)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sansone). Model: ❑ Shear Velvets). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chairi Dispenser ID: Dispenser ID: ❑Dispenser Containment ❑ Dispenser Containment Sansone). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(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 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): DAVE WINKLER Signature: W Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2"'STREET GALT,CA 95632 Date of Testing/Servicing: -4-18-2016 Monitoring System Certification Page 1 of 4 2/21/07