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REDEAppendix VI NE MONITORING SYSTEM CERTIFICATION II I1�'' (� gg ia Authority cited: Chapter 6.7, Health and rsafety Code;use By All Chapte 1dictions 16,IDivision 3,Title the State of 23,California Cott UU R1 1j7JrTs This form must be used to document testing and servicing of monitoring equipment.A separate certification [�P o u �arAe�rL�for each monitoring system control panel by the technician who performs the work.A copy of this form must bAW"Wg4'fAL HEALTH owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 3 t�d@� A. General Information ��PA I HENT Facility uo,,,e .F. KLUDT AND SONS-CARDLOCK Site Bldg.No.: Address 1126 E.PINE ST. City: LOD] Facility Contac[ Zip: 96240 Parson: STEVE Contact Phone No.: (209)368-0634 Make/Model of Monitoring System: VEEDER ROOT TLS 360 Date of Testing/Servicing: 4/1/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicatespecific a ui ment ins ectad/serviced: [E] nklD: 20K CLEAR DIESEL TanklD: 10K RED DIESEL In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 Annular Space or Vault Sensor. Model: 420 ® Annular Space of Vault Sensor. Model: 420 Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Madel: Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: Fx 1V Electronic Line Leak Detector. Motlel: D Electronic Line Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: D Tank Overfill/High-Level Sensor. : D Other(specify equipment type and model in Section E on Page 2). Model ❑ Omer(specify ify equipment type and model in Section E on Page 2). Tank ID: 10K RED DIESEL SYPHON TANK Tank ID: ® In-Tank Gauging Probe. Model: MAG 1 D In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 D Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 208 D Piping Sump/Trench Sensor(s). Model: D Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: NONE D Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: ❑ 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), Cl Other(specify equipment type and model in Secon E on Page 2). Dispenser ID: 7/8 Dispenser ID: 9/10 ® Dispenser Containment Sensors). Model; 208 ® Dispenser Containment Sensors). Model: 208 ® Shear Valve(s). ® Shear Velvets). D Dispenser Containment Floaks)and Chain(s). D Dispenser Containment Float(e)and Chain(s). Dispenser ID: 9 SATELITE Dispenser ID: 10 SAT/11 SAT ® Dispenser Containment Sensors). Model: 208 ® Dispenser Containme ® Shear Valve(s). nt Sensors). Model: 206 ® Shear Valve(s). D Dispenser Containment Floats)and Chain(s). D Dispenser Containment Floats)and Chain(s). Dispenser ID: 11/12 Dispenser ID: 13/14 ®Dispenser Containment ® Dispenser Containment Sensors), Model: 208 Sensor(s). Model: 208 ® Shear Velvets). ®Shear Valve(s). D Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chaints). If the facility contains more tanks or dispensers,copy this form. Indude infofmabon 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,1 have also attached a copy of the report,frhech all that apply): ®System set-up ®Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A28448 License No: U4-1676 Testing Company Name. AFFORDA-TEST Phone No. (209)7440113 Testing Company Address: 478 2 STREET GALT,CA 96632 Date of Testing,S .. ing. 4/V14 Monitoring System Certification Page 1 of 4 2/21/07