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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 monitonng equipment.A separate certification or report must be prepared for each monitonng 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 Name: E.F.KLUDT AND SONS Bldg.No.: Site Address: 1126 E.PINE City: LODI Zip: 96240 Facility Contact Person: STEVE Contact Phone No.: (209)3SM634 Make/Model of Monitoring System: TL 360 f RONAN X76S Date of Testing/Servicing: 4r7/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment ins ectad/serviced: 7orVault : KEROSENE Tank Size' Tank ID: 110 OCT Tank Size: nk Gauging Probe. Model: MAG-1 ® In-Tank Gauging Probe. Model: MAGI lar Space or Vault Sensor. Model: LS3 ® Annular Space or Vault Sensor. Made]: LS3 Sump/Trench Sensor(s). Model: 208 M Piping Sump/Trench Sensor($). Model: 208 mp Sensor(s). Model: D Fill Sump Sensor(s). Modelanical Line Leak Detector. Model: LD 2000 ® Mechanical Line Leak Detector. Model: RJ XLP onic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. ModelOverfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: (specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2), Tank ID: Tank Size: Tank ID: Tank Size: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: LFRImp/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: Sensor(s). Model: ❑ Fill Sump Sensor($). Modelal Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. ModelLine Leak Detector. Model: ❑ Electronic Line Leak Detector. Modelrfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Modelecify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and made]in Section E on Page 2). Dispenser ID: 110 OCT/KEROSENE Dispenser ID: ® Dispenser Containment Sensor(s). Model: 208 E] Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ® Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Vaive(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: [I Dispenser Containment El Dispenser Containment Sensor($). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser containment Floats)and Cham(s). ❑ Dispenser Containment Float(s)and Chain(s). If the facility contains more tanks or dispensers,copy this forth. Include imormanon for every tank and dispenser at the facility. C.Certification-1 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 a0 rhal apply): ®System set-up ®Alarm history report Technician Name(pint): Ed Steams Signature: �1° .. Certification No.: A31048' License No: Testing Company Name. AFFORD^-TEST Phone No. 1209)744-0113 Testing Company Address: 416 2n°STREET GALT,CA 95632 Date of Testing/Servicing. 3/7/16 Monitoring System Certification _ r yy,J, Page 1 of (� 2/21/07 MAY 0 2 2016 MAY 0 2 !016