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GEIVED .. Appendix VI JUL It 0 2016 MONITORING SYSTEM CERTIFICATION ENVIRON44FNTALHTH Authority Cited: Chapter 6.7, Health andrsafety C de;Use By AllsChaptdictionser 16ithi,IDiv Division 3, Titlethe State ofrnia 23,California Code of Regu a PERLI'IT ��VICE This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for 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: UNITED GAS Bldg.No.: Site Address: 3440 E. MAIN ST City: STOCKTON Zip: 95205 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: GILBARCO EMC Date of Testing/Servicing: 6/272016 B. Inventory of Equipment Tested/Certified Check thea pro riate boxes to indicate specific equipment inspectedlserviced: Tank ID: 91 Tank Size: Tank ID: 89 Tank Size: ® In-Tank Gauging Probe. Model: MAG 2 M In-Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Moder 420 ® Piping Sump/Trench Sensor(s). Model: 205 ® Piping Sump/Trench Sensors) Model: 2 0 5 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: RJ-FX-IV M 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 p type and model in Section E on Page 2). Tank ID: Tank Size: Tank ID: 87 Tank Size: dfl In-Tank Gauging Probe. Model: ® In-Tank Gauging Probe. Model: MAG I ❑ Annular Space or Vault Sensor. Model: ® Annular Space or Vault Sensor. Model: 420 z0 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: R J-X L P ❑ 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: ❑ Dispenser Containment Sensor(s). Model'. ® Shear Valve(s). ® Shear Valve(s). I@ Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Cham(s). Dispenser ID: 5 / 6 Dispenser ID: 7 / 8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s)and Cham(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 M Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No. A28446 License No 04-1676 Testing Company Name: AFFORDA-TEST Phone No. X209)7440113 _ Testing Company Address: 416 2"d STREET GALT,CA 95532 Date of Testing/Servicing: 6/27/2016 Monitoring System Certification Page 1 of 4 2/21/07