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RECEIVED Appendix VI APR 2 3 2018 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 Cod"QM81I gENTAL This form must be used to document testing and servicing of monitoring equipment.A separate certification or report muTgr{glpqRTMENT each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to a 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 Name: JAHANT FOOD & FUEL Bldg,No.: Site Address 24323 N. HIGHWAY 99 City: ACAMPO zip: 95220 Facility Contact Person: SINGH Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 4/12/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment ins ectad/serviced: Tank ID: 87 OCT Tank Size: 10 K Tank ID: 89 OCT Tank Size: 5 K ® In-Tank Gauging Probe. Model: M A G 7 ® in-Tank Gauging Probe. Model: M A G 7 ® Annular Space or Vault Sensor. Model: 4 2 0 ® Annular Space or Vault Sensor, Model: SHARED W/ 87-91 ® Piping Sump/Trench Sensor(s). Model: 2 0 8 ® Piping Sump/Trench Sensor(s). Model: 2 0 8 D Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model 99 LD 2000 ® Mechanical Line Leak Detector, Model: 99 LD 2000 D Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: D Tank Overfill/High-Level Sensor. Model: D Other(specify equipment type and model in Section E on Page 2), D Others ec equipment ( p dY type and model in Section E on Page 2). Tank ID: DIESEL Tank Size: 20 K Tank ID: 91 OCT Tank Size: 5 K ® In-Tank Gauging Probe, Model: MAG 7 ® In-Tank Gauging Probe. Model M A G 7 ® Annular Space or Vault Sensor. Model: 4 2 0 ® Annular Space or Vault Sensor. Model: SHARED W/ 87-89 ® Piping Sump/Trench Sensor(s). Model: 2 0 8 ® Piping Sump/Trench Sansone). Model: 2 O 8 D Fill Sump Sensors). Model: D Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 2000 D Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: D Tank Overfill/High-Level Sensor. Model: ❑ 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: I / 2 & 3 / 4 Dispenser ID: 5 / 6 & 7 / 8 ® Dispenser Containment Sensogs). Model: 2 0 8 & 2 0 8 ® Dispenser Containment Sensor(s). Model: 2 0 8 & 2 0 8 ® Shear Valve(s). ® Shear Valve(s). D Dispenser Containment Floats)and Chain(s). D Dispenser Containment Fioahs)and Chain(s). Dispenser ID: 9 / 10 Dispenser ID: 11 / 12 ® Dispenser Containment Sansone). Model: 2 0 8 ® Dispenser ContainmentSensor(s). Model l O 8 ® Shear Valve(s). ® Shear Valve(s). D Dispenser Containment Floats)and Chain(s). D Dispenser Containment Float(s)and Chain(s). Dispenser ID: 13 / 14 Dispenser ID: 15 / 16 ® Dispenser ContainmentSenwgs). Model: 2 0 8 ® Dispenser Containment Sensor(s). Model: 2 O 8 ® Shear Valve(s). IH Shear Valve(s). D Dispenser Containment Floats)and Chain(s). D Dispenser Containment Float(s)and Chain(s). 'If the facility contains more tanks or dispensers,copy this torn. 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): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 2" STREET GALT,CA 96632 Date dTesting/Servicing: 4/12/2018- Monitoring System Certification Page 1 of 4 2/21/07