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V,W vi Appendix VI 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, California Cade of,R99qI;itl ,y This form must be used to document testing and servicing of monitoring equipment,A separate certification or report muss be prepared 6?, each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system Ownerloperator.The ownerloperator 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: UNITED GAS Bldg.No.: Site Address: 3440 E MAIN ST City: STOCKTON CA Zip: 95206 Facility Contact Person: Contact Phone No.: ............ Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of TestingIServicing: 2/212018 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecific eguipment ins pec ediservIlGed: Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: • In-Tank Gauging Probe. Model: MAG 1 0 In-Tank Gauging Probe. Model: MAG I • Annular Space or Vault Sensor. Model: 420 0 Annular Space or Vault Sensor. Model: 420 • Piping Sump!Trench Sensor(s). Model: 206 Ej Piping Sump!Trench Sensor(s). Model: 206 ❑ Fill Sump Sensor(s), Model: (3 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: REDJACKET0 Mechanical Line Leak Detector. Model: BIG FLO El Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector, Model: El Tank Overfill/High-Level Sensor, Model: El Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment type and model in Section E on Page 2). [1 Other(specify equipment type and model in Section E on Page 2). Tank ID: 89 Tank Size: Tank 1D: Tank Size; • In-Tank Gauging Probe. Made[: MAGI El In-Tank Gauging Probe. Model: • Annular Space or Vault Sensor. Model: 420 0 Annular Space or Vault Sensor. Model: [K Piping Sump/Trench Sensor(s). Model: 206 El Piping Sump/Trench Sensor(s). Model: El Fill Sump Sensor(s), Model: El Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 99LD 2000 El Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. model; Ll Tank Overfill I High-Lave!Sensor. Model: [I Tank Overfill/High-Level Sensor. Model: [I Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section F on Page 2). Dispenser ID: 1-2 Dispenser ID: 7-8 El Dispenser Containment Sensor(s). Model: FLOATS El Dispenser Containment Sensor(s). Model: FLOATS t9 Shear Valve(s). 0 Shear Valve(s). 9 Dispenser Containment Float(s)and Chain(s). R Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 Dispenser ID: El Dispenser Containment Sensor(s). Model: FLOATS 0 Dispenser Containment Sensor(s). Model: * Shear Valve(s). N Shear Valve(s). * Dispenser Containment Float(s)and Chaln(s), El Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: N Dispenser Containment 0 Dispenser Containment Sensor(s). Model: FLOATS Sensor(s). Model: ISI Shear Valve(s). 0 Shear Valve(s). 19 Dispenser Containment Float(s)and Chain(s). E] Dispenser Containment Float(s)and Chain(s). 1f 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 Z Alarm history report Technician Name(print): David Winkler Signature: ��j Certification No.: 5263373-Ulr License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 21d STREET GALT,CA 95632_ Date of Testing/Servicing: 2-2-2018 2/21/07 Monitoring System Certification Page 1 of 4