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• Appendix VI • 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 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 ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility JAHANT FOOD AND FUEL Bldg. No.: _ g. Site Addresa 24323 N. HWY 99 _ City: ACAMPO Zip: 95240 Facility Contact Parana SINGH Contact Phone No.: (209) 333-9000 Make/Model of Monitoring System: GILBARCO TANK MONITOR 3 & INCON TS 1000 Date of Testing/Servicing: 4/8/2010 a. Inventory of Equipment Tested/Certified Chock fhe annrnnriaf. hnreg fn Indinafw gnprifir. enninmant Insnected/serviced: Tank ID: 87 OCT s Tank ID: 89 OCT ® In -Tank Gauging Probe. Model: MAG _ ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: EIS _ ® Annular Space or Vault Sensor. Model: SAME TANK ® Piping Sump / Trench Sensoria). Model: ULS _ ® Piping Sump / Trench Sensor(s). Model: ULS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: STP ML._D 2 Mechanical Line Leak Detector. Model: STP MLD ❑ 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: DIESEL 2 GILBARCO MONITOR ONLY Tank ID: 91 OCT ® In -Tank Gauging Probe. Model: MAG _ ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: 420 _ (0 Annular Space or Vault Sensor, Model: SAME TANK AS ABOVE ® Piping Sump I Trench Sensoria). Model: 208 _ ® Piping Sump / Trench Sensoria). Model: ULS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model. ® Mechanical Line Leak Detector. Model: 99 LD 20_00 ® Mechanical Line Leak Detector. Model: STP MLD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill I 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: 112 Dispenser ID: 3/4 ® Dispenser Containment Sensor(s). Model: ULS _ ® Dispenser Containment Sensor(s). Model: ULS ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats) and Charts). (3 Dispenser Containment Float(s) and Charts). Dispenser ID: 516 s Dispenser 10: 718 ® Dispenser Containment Sensoria). Model: ULS _ 21 Dispenser Containment Sensor(s), Model: ULS ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) 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 Floats) and Crainia). ❑ 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 Inspectedlservlced 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): ZANE NIMMO Signature: --L®L---� — — Certification No.: A28446License No: 04-1676 Testing Testing Company Name: AFFORDA-TEST _ Phone No. (209) 744-0113 Testing Company Address: 416 2 STREET GALT, CA 95632 Data of Testing/Servicing: 4/8/10 _ Monitoring System Certification Page 1 of 4 2/21)07