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Appendix VI ..i 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 of R 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. N 3 A. General Information F % ?0 Facility Name: BJJ TRUCKING �✓ 13 Bldg.No.: /h... 11`Ar�. Site Address: 243SA 1 E MARIPOSA City: STOCKTON CA r 1 2jp: '4,7 H Facility Contact . FF9(T�, Pwsnn GAYLEN Contact Phone No.: ( ) S Make/Model of Monitoring System: INCON 1001 Date of Testing/Servicing: 5/22/2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: DSL EAST Tank ID: DSL WEST ® In-Tank Gauging Probe. Model: MAG ® 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 ❑ Fill Sump Sensor(s). Model: - El 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). TanklD: TanklD: 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: 0 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). DispenserlD: 1-2 Dispenser ID: ® Dispenser Containment Sensor(s). Model: ULS ❑ Dispenser Containment Sensor(s). Model. ® 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 Sensors). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(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.manufacturerschecklists)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: Certlfcation No.: 5263373-UT License No: 05-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 STREET GALT,CA 95632 Date of Testing/Servicing: 5-22-13 Monitoring System Certification Page 1 of 4 2/21/07 Q�,ah �uZ�v tr E+4