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V I Appendix VI pD ,J�,'v it MONITORING SYSTEM CERTIFICATION ENVIRU��tENt(�1 For Use By All Jurisdictions Within the State of California pp�� i IEAr Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23,Californi �btl17 �E , FH Regulations ^ CES 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 Bldg.No.: Name: BBJ TRUCKING g Site Address: 2431 EAST MARIPOSA ROAD City: STOCKTON Zip: 95205 Facility Contact Person: Contact Phone No.: (209)941-2576 Make/Model of Monitoring System: INCON 1001 Date of Testing/Servicing: 05-26-10 B. Inventory of Equipment Tested/Certified Check thea pro nate boxes to indicates ecific equipment Ins acted/serviced: Tank ID: NORTH DIESEL Tank ID: SOUTH DIESEL S In-Tank Gauging Probe. Model: MAG S In-Tank Gauging Probe. Model: MAG S Annular Space or Vault Sensor. Model: ULS S Annular Space or Vault Sensor. Model: ULS S Piping Sump/Trench Sensor(s). Model: ULS S Piping Sump/Trench Sensorial Model: ULS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: S Mechanical Line Leak Detector. Model: STP MLD S Mechanical Line Leak Detector. Model: STP MLD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: D Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). T Tari TanklD: ❑ 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 Sensoria). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: [3 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: 3.41 S Dispenser Containment Sensor(s). Model: ULS S Dispenser Containment Sensoria). Model: ULS S Shear Valve(a). S Shear Valve(s). ❑ Dispenser Containment Floal(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). �! Dispenser ID: DispenserlD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensoria). Model: ❑ Shear VaNe(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensoria). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Hostile)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): FELIX RAMIREZ Signature: 11/x-- ":.::> Certification No. 5273934-UT License No: 06-1740 -� - Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 STREET GALT,CA 95632 Date of Testing/Servicing: 05-28-10 _ Monitoring System Certification Page 1 of 4 2/21 ()7