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qp V RECEIVEL Appendix VI MONITORING SYSTEM CERTIFICATION JUN 18 2015 For Use ty All Jurisdictions r 16, the State of Title 23 8NMM MENTAL Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California C This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must g0Fpar( Ia=DIltOT4/CRIT 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: Site Address: Facility Contact Person: JAMAR SVC Bldg. No.: 4076 EAST MAIN STREET City: STOCKTON Zip: Contact Phone No.: (209) 462-4686 Make/Model of Monitoring System: VEEDER ROOT TLS 360 Date of Tesfing/Servicing: 611912016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to ntelcate s earn a ur linen. ria TanklD: 87 Tank ID: 91 N In -Tank Gauging Probe. Model: MAG 1 N In -Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model: 409 N Annular Space or Vault Sensor. Model: SPILT 187 N Piping Sump / Trench Sensor(s). Model: 208 N Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: �E PETRO N Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Ovefill / 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). TanklD: TanklD: ❑ 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 / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Motlel: ❑ 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 lD: 1.2 Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: N Shear Velvets). N Shear Valve(s). N Dispenser Containment Float(s) and Chain(s). N Dispenser Containment Floats) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: N Shear Valve(s). N Shear Velvets). N Dispenser Containment Float(s) and Chain(s). N Dispenser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Velvets). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). .........., r,., e.,ne. 6 ann dicnenner at the facility. 9fthe facility coni more umK5 or a15Pe1svm, wyy um "mw I 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 dial apply): N System set-up N Alarm history report Technician Name (print): FELIX RAMIREZ Signature: Certification No.: B34976 License No: 5273934 -UT 08-1740 OTTL Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 418 2" STREET GALT CA 95632 Date of Testi Servicing: 05-19-15 Monitoring System Certification Page 1 of 4 2/21/07