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ED Appendix VI GEIV SEP 1 h n 20�/ �j MONITORINGSYSTEMSYSTons tEIM CERTIFICATIthin the State of ION ENMRO&MENTAL HEA) rH For Use Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16, Division 3,Title 23,California Code off)T/SERWIES Regulations 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: MANPREET Contact Phone No. (925)9T4-W3 Make/Model of Monitoring System: GILBARCO EMC Date of Testing/Servicing: 06-27-17 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: _ TanklD: 87 TanklD: 91 ® In-Tank Gauging Probe. Model MAGI M In-Tank Gauging Probe. Model. MAGI ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 O Fill Sump Sensors) Model ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model. RED JACKET ® Mechanical Line Leak Detector. Model. RED JACKET ❑ Electronic Line Leak Detector. Model. ❑ Electronic Line Leak Detector. Model. ® Tank Overfill/High-Level Sensor Model FLAPPER ® Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ 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: 89 Tank ID: ® In-Tank Gauging Probe Model ❑ In-Tank Gauging Probe Model: t ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model. 99 LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ 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: 34 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Floats)and Chaints). ® Dispenser Containment Float(s)and Chain(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 Chain(s). ® Dispenser Containment Float(s)and Chainis). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Floats)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 ❑Alarm history report Technician Name(print): Signature: �- Certification No. 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)7440113 Testing Company Address: 416 2n°STREET GALT CA 95632 Date of Testing/Servicing: DO-27-17 Monitoring System Certification QC 17 of 4 2/21/07 AJC C�