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RECEIVED Appendix VI OCT 112017 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,Califorr[ R ®WT1)AL HEALTH This form must be used to document testing and servicing of monitoring equipment.A separate cert8ication or report must b l hf TMENT each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the an system owner/operator.The owner/operator must submit a copy of this form to the local agency regulating OST systems within 30 days of test date. A. General Information Facility Name: KWIK SERV Bldg.No.: Site Address: 824 E. YOSEMITE AVE. City: MANTECA zip: 95336 Facility Contact Person: JUENDER Contact Phone No.: ( ) Make/Model of Monitoring System: GILBARCO EMC Date of Testing/Servicing: 6/26/2017 B. Inventory of Equipment Tested/CereNed Check the appropriate boxes to indicatespecific equipment Ins ted/serviced: Tank ID: 87 Tank Size: Tank ID: 89 Tank Size: ® In-Tank Gauging Probe. Model: MAG 2 ® In-Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump/Trench Senors). Model: 205 ® Piping Sump/Trench Sensogs). Model: 205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 19 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 2 ❑ Annular Space or Vault Sensor. Model: ® Annular Space or Vault Sensor. Model: SHARED W/ 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 Leak 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: 1 / 2 Dispenser ID: 3 / 4 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Dispenser Containment Sensogs). Model: 2 0 8 ® Shear Valve(s). ® 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: 208 ® Dispenser Containment Sensogs). Model:208 ® Shear Valve(s). ® Shear Valve(s). ❑ 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: ❑ 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 19 Alarm history report Technician Name(print): ZANE NIMMO Signature: TJX Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2n°STREET GALT,CA 95632 Date of Testing/Servicing: 6/26/2017 Monitoring System Certification Page 1 of 4 2/21/07