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%%.s Appendix VI a.( 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 Code / This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared foF''��•` E I Y �E® 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 lest date. JUIN 2 O 2012 A. General Information Facility BJJ TRUCKING Bldg.No.: CP'VIRON ENTAIL HMLt1 ua_e Site Addreac' 243SA 1 E MARIPO City: STOCKTON CA zip: PERMIT/SERVICEIA Facility Contact GAYLEN Contact Phone No.: ( ) Parcnn' Make/Model of Monitoring System: INCON 1001 Date of Testing/Servicing: 5/212012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment fns ectedlserviced: Tank ID: DSL EAST Tank ID: DSL WEST ® In-Tank Gauging Probe. Model: MAG I@ In-Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: ULS ® Annular Space or Vault Sensor. Model: ULS ® Piping Sump/Trench Sensor(s). Model: ULS ® Piping Sump/Trench Sensor(s). Model: ULS ❑ Pill Sump Sensor(s). Model ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FE PETRO ® Mechanical Line Leak Detector Model: FE PETRO _ ❑ 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 ID: NA ❑ 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. Model: ❑ 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: ® Dispenser Containment Sensor(s). Motlel'. ULS ❑ Dispenser Containment Sensor(s). Model: _ (j Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 Dispenser ID: ® Dispenser Containment Sensor(s). Model: ULS ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Cham(s). ❑ Dispenser Containment Float(s)and Chalets). 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)'. DAVE WINKLER Signature: Certification No.: 5263373-UT License No: 08-1738 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 STREET GALT CA 95632 Date of Testing/Servicing: 5-2-2012 ------ Monitoring System Certification Page 1 of 4 2/21 ill? ,5j C_