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I 0 0 Appendix VI (Copies of Mondonng System Certification form and UST Monitoring Plot Plan available at httD/hwyv.waterbuards.ca aov.) 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 tans must be used b document testing and servidng of monitoring equipment A separate certification or report must be prepared for each monitoring system control Panel by Me Wool who pedamrs Me work. A copy of this font must be provided to the tank system own sooperetor. The ownerloperstor must submit a copy of Mis form to Me Ideal agency regulating UST systems within 30 days of test date. A. Ganeml Information Facility JANAW FOOD AND FUEL Bldg. No.: Site Site• Add.24323 NORTH HIGHWAY 99 City: ACAMPO lip: 95240 a' Fadlity Contact SINGH Contact Phone No.: (209333E000 Person' MakayModel of Monitoring System: INCON TS 100) Date M Testing/Servidng: Apri19. 2009 B. Inventory of Equipment Tested/Certified Tank ID: 87 Tank ID: 91 X In -Tank Gauging Probe. Model: MAG 1 X In -Tank Gauging Probe. Model: MAG 1 X Annular Spew or Vault Sensor. Model! EIS X Annular Space or Vault Sensor. Model: SPLIT WI 87 AND 89 X Piping Sump/ Trench Senors). Model: ULS X Piping Sump/ Trench Senors). Model: ULS D Fill Sump S.mu,rsl. Model D FII Sump Sensoria). Model: X Mechanical Line Leak Detecto, Model, PE PETRO X Mechanical Line Leak Detector, Model: PE PETRO D Electronic Line Leak Detector. Model: D Bectronic Line Leak Detector. Model: D Tank Overfill / High -Level Sensor Model: D Tank Overfill / HI9RLevel Sensor. Model: D Other (specify equipment type and model In Section E on Page 2), D Other (sprol equipment type and model in Section E on Page 2), TanklD: 89 Tank ID: X In -Tank Gauging Probe. Model: MAG1 D In -Tank Gauging Probe. Model: X Annular Spam or Vault Sensor. Model: SPLIT W/91 AND 87 D Annular Space or Vault Sensor. Motlel: X Piping Sump I Trench Someone), Model: ULS ❑ Piping Sump I Tmnch Sensoria). Model: D Fill Sump Sansone). Model : ❑ FII Sump Someone). Model: X Mechanical Line Leak Detector. Model: PE PETRO D M.Am mlczl Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Electronic Lina Leek Delecmr. Model: D Tank Ovedlll I High -Level Senso, Model: D Tank Dwell / High -Level Sensor. Model: D Other (specify equipment type and model in Section E on Page 2). D Other (specify equipment type and model In Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 34 X Dispenser Containment Sonsor(s). Model: ULS D Dispenser Containment Sensor(s). Model: ULS D Shear Vaive(s). D Shear Velve(s). D Dispenser Containment Realist and Chalms). D Dispenser Containment Real and Chan(s). Dispenser ID: 5.6 Dispenser ID: 7-8 D Dispenser Containment Sensor(s). Madel: UIS D Dispenser Containment Semons). Model: ULS D Shear Velve(s). D Shear Velva(s), D Dispenser Containment Floats) and Chain(s). D Dispenser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment D Dispenser Containment Someone). Model: Sensor(s). Model: D Sheer VidNit.). ❑ Shear Valve(s). D Dispenser Containment Floats) and Chain(&). ❑ Dispenser Containment Floats) and Cheln(s). -It in. raunry mmemo more amse ur....... —, wvr Sun lou^. ^^"""� ^"^ ^""•••"•"•_.�._.... _..__._.�.__. _-_._.__...... C. Certification . I certify that the equipment identified In this document was Inspectedlseiviced in accordance with the manufacturers' guidelines. Attached to this Cenfication 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; (eheet all Mar apply): D System set-up D Alarm history report Technician Noma (Pont): Felix Ramirez _ Signature: &I -C." Cedifimtion No.: 2958213781 Limnos No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (2091744-0113 Testing Company Address: 418 STREET GALT CA 9511 Data at TesgnglSovicing: Alan 92009 Monitoring System Codification Page 1 of 4 2/21/07 �c st�