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• G RECEIVED Appendix VI SEP 2 8 2016 MONITORING SYSTEM CERTIFICATION 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,Californ' �16OWp(�r�`�fpftT& HEALTH This fano must be used to document tesgng and servicing of monitoring equipment.A separate certification or report must be hrll�c�st'C1fi'ITM ENT each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the t owner/operator.The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: QUICK & EASY FOOD MART Bldg.No.: Site Address: 824 E. YOSEMITE AVE. City: MANTECA Zip: 95336 Facility Contact Person: JITENDER Contact Phone No.: ( ) Make/Model of Monitoring System: GILBARCO E M C Date of Testing/Servicing: 6/27/2016 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecific equipment ins ectad/serviced: Tank ID: 87 Tank Size: Tank ID: 89 Tank Size: ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG I ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 4 2 0 ® Piping Sump/Trench Sensogs), Model: 2 0 5 ® Piping Sump/Trench Sensor(s). Model: 205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Seasons). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ 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: Tank Size: Tank ID: 91 Tank Size: ❑ In-Tank Gauging Probe. Model: ® In-Tank Gauging Probe. Model: MAG I ❑ Annular Space or Vault Sensor. Model: ® Annular Space or Vault Sensor, Model: SAME AS 89 ❑ Piping Sump/Trench Sensor(s). Model: ® Piping Sump/Trench Sensor(s). Model: 205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leek Detector. Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ 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: I / 2 Dispenser ID: 3 / 4 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Velvets). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5 / 6 Dispenser ID: 7 / 8 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Dispenser Containment Sensor(s). Model: 2 0 8 0 Shear Valve(s). ® Shear Velvets). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shearvalve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chaln(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;(rheck all that apply): ®System set-up ®Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A26446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date of Testing/Servicing: 6/27/2016 Monitoring System Certification Page 1 of 2/21/07