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NOV-13-2013 15:12 From: 2098254549 To:4683433 Paee:14119 Appendix VI MONITORING SYSTEM CERTIFICATION For Use By An Jursoictions within the State of California Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23,California Code of Regulations Thisformrhust be used to dowmem teeing and Servicing ofmoAaonng equipment.Aseparste cerufforion orreport must tepreparedfor RECEIVED aeon monitoring system control panel by the technician who performs the want.A Copy of this form must be provided to the tank MS.w onerloperator.The owner/operator must submits copy of thin form to the local agency regulating VST Systims within 30 days of teat date. A. General lydormaaon Facility Name. QuICKI KLeeN Sidg.No. N OV 12 2013 Site Address707 E YOSEMITE AVE City MANTECACA Zip'. Fadrlry Contact PP.h ConladPhoneNo.. , FALyiR )NMENTAL MakwModel of Monitoring System: VEEDER ROOT TLS 360 Date of Tistingsannang: 10116re91!'IEALTH DEPARTMENT e. Inventory of Equipment Teeled/Ceniffed Check the appropriate boxes to indicate S echic Muiptneritinepectad/serviced: Tank ID: 871 Tank 10 872 ® In-Tank Gauging Probe. Model: MAG 0 W In-Tank Gauging Probe. Model: MAG O ® Annular Space or Vauk Sensor Model: 420 Q Annular Space or Vaurt Sensor Model: SPLIT ® Piptrg Sump/Trench Sensor(s). Madel: 208 ® Piping Sump/Trench Sensoris), Model'. 208 ❑ Fill Sump Sensor($), Model: ❑ Fill Sump Sensor[$). Model. ® Mechanical Line Leak Detector. Model: 99LO 2000 ® Moctgnical Line Leak Detector Model,. FE PETRO 0 Electronic Line Leak Detector. Made; ❑ Electronic Line Leak Detector. Wast. ❑ Tank Overfill/High-Level Sensor, Model ❑ Tank Overfill/High-Level Sensor. Model ❑ Other(specify equipment type and model in$ection E On Page 2). ❑ Omer(specify equipment type and model in Sector,E on Page 2i, Tank ID' DSL Tank ID: NA 0 In-Tank Gauging Probe. Model. MAG O El In-Tank Gauging Probe. Model. ❑ Annular Space or Vaua Sensor. Model: SPLIT ❑ Annular Space or Vault Sensor. Model'. ® Piping Sump/Trench Sensors) Moder 208 ❑ Piping Sump/Trends Sensors). model: ❑ PHI Sump Sansor(s). Model', ❑ Fill Sump SansW(S) Model. ® Mecnaincal Una Leak Detector. Model. FE PETRO D ❑ Mechanical Line(Leak Detacty, Model: I] Electronic Line Leak Defector. Model. Q Electronic Une Leek Detector. Model ❑ Tank Overfill1 High-Level Sensor. Modal ❑Tank Overfill/High Level Sen$01 Motlel'. ❑ Other(specify equipment type and mode in Section E on Page 2). ❑ Other(Specify equipment type and model in Section E or.Page 2) Dispenser ID: 1.2 Dispenser 10: 5-6 ® Disten$er Contaminant Senso,du Model: 2011 0 Dispenser Comainmenl San$or(S). MOM 2011 N Sneer Va"(s) ® Shear VaNe(s). ❑ Dispenser Containment Fidet(a)ono Chain(g). ❑ Dispenser Conlainmenl Floats)and Chain($). Diapenssl 3.4 Dispenser ID'. 7-8 ® Dispenser Containment Sensor($). Model: 208 14 Dispenser Containment Sensorls). Model: 206 ® Sheer VeNe(S). ® Shear Velvets). ❑ Dispenser ConlainmeM Roat(S)and Chainfa). ❑ Dispenser Containment Foat(e)and Churls). Dispenser In Dispenser ID; ❑Dispenser Containment ❑ Dispenser Containment Senser(s), Model: Sensor($). Model: ❑ Shear Varre(s) ❑Shear Vafvals). ❑ Data,,Containment Fantle)and Chain(s). ❑Dispenser Containment Floats)and Ohain(s). "If the facility comama more ranks or oi$penseiS,copy this form. Include information for every tank and dispenser at the facility. C.Ceinnficadon-I certify Nat the equipment idenfified in this document was inspectedn entieeo in acconchi weh the manufacturers' guidelines.Attached to this Certification is Information(e.g.mamdaeturps'chacklials)recess try to verify that this Information is correct and a Plot Ran showing the layout of monitorinequipment For any equipment eapaMe of generating such reports.I have also attached a copy of the report;(check as tasty ly/: F System set-up 0 Alarm history report Technician Name(print) DAVEWNKLER Signature: '",,v Certification No.: 5263373-UT --�- — License No. 08-1739 _ "`— Testing Company Name: AFFORDA-TEST ---- Phone No. Testing Company Address' dib STREET GALT,CA95e$2 _. Date of TeMing/Servicing'. 10-1613 M ichlbring System Certification Page 1 of 4 2/21/07