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ht(.J:: 1VLU <br /> 1.04 <br /> Appendixes APR 2 6 2017 <br /> MONITORING SYSTEM CERTIFICATION <br /> For Use By All Jurisdictions Within the State of California <br /> Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16, Division 3,Title 23,Califcffi�M"M(IFMEALTH <br /> This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared fr)7)E PARTM ENT <br /> each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system <br /> 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. <br /> A. General Information <br /> Facility Name: JAHANT FOOD & FUEL Bldg,No.: <br /> Site Address: 24323 N. HWY 99 City: ACAMPO Zip: 95220 <br /> Facility Contact Person: SINGH Contact Phone No.: ( ) <br /> Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 4/132017 <br /> B. Inventory of Equipment Tested/Certfified <br /> Check the approprials boxes to indicate sp2cific equipment ins ected/serviced: <br /> Tank ID: 87 Tank Size: Tank ID: 89 Tank Size: <br /> ® In-Tank Gauging Probe. Model: MAG 7 ® In-Tank Gauging Probe. Model: MAG 7 <br /> ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: SHARED VESSEL <br /> ® Piping Sump/Trench Sensor(s). Model: 2 0 8 ® Piping Sump/Trench Sensor(s)- Model: 208 <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 2000 <br /> ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Mortal: <br /> 0 Tank Overall/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model. <br /> ❑ Other(specify,equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). <br /> Tank ID: DIESEL Tank Size: Tank ID: 91 Tank Size: <br /> ® In-Tank Gauging Probe. Model: MAG 7 ® In-Tank Gauging Probe. Model: MAG 7 <br /> ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: SHARED W/87/89 <br /> * Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensar(s). Model: 208 <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> 0 Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 2000 <br /> ❑ Electronic Line Leak Detector. Mode[: ❑ Electronic Line Leak Detector. Model: <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). <br /> Dispenser ID: 1/2 & 3/4 Dispenser ID: 5/6 & 7/8 <br /> ® Dispenser Containment Sensor(s). Model: 208 & 208 ® Dispenser Containment Sensor(s). Model: 2 0 8 & 2 0 8 <br /> ® Shear Valve(s). ® Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> DispenserlD: 9/10 DispenserlD: 11/12 <br /> ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Dispenser Containment Sensor(s). Model: 208 <br /> ® Shear Valve(s). ® Shear Valve(s). <br /> ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> DispenserlD: 13/14 DispenserlD: 15/16 <br /> ® Dispenser Containment <br /> ® Dispenser Containment Sensots), Model: 208 Sensor(s). Madel: 208 <br /> ® Shear Valve(s). ®Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Cham(s). <br /> 'If the facility contains more tanks or dispensers,copy this form. Include Information for every tank and dispenser at the facility. <br /> C.Certification-I certify that the equipment identified in this document was Inspected/serviced in accordance with the manufacturers' <br /> guidelines.Attached to this Certification is information(e.g.manufacturers'checklists)necessary to verity that this information Is correct <br /> and a Plot Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a <br /> copy of the report;(ehmk all that apply): ®System set-up ®Alarm history report <br /> Technician Name(prim). ZANE NIMMO Signature: <br /> Certification No.. A28446 License No: 041676 <br /> Testing Company Name: AFFORDA-TEST Phone No. (208)744.0113 <br /> Testing Company Address: 416 2n°STREET GALT,CA 95632 Date of Testing/Servicing: 4/132017 <br /> Monitoring System Certification Page 1 of 4 2/21/07 <br />