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Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Californiar,DD I n rf rt,s Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23,California Code h lPti47s This toren must be used to document testing and servicing of monitoring equipment.A separate certification or report muster ,". r each monitoring system control panel by the technician who performs the work.A copy of this form must be provided tp, s � VK L; _ owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 7�q sP(tgpfj tt 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)368-0634 Make/Model of Monitoring System: TL 350/ RONAN X76S Date of Testing/Servicing: 477/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: KEROSENE Tank Size: Tank ID: 110 OCT Tank Size: ® In-Tank Gauging Probe. Model: MAG-1 ® In-Tank Gauging Probe. Model: MAGI ® Annular Space or Vault Sensor. Model: LS3 ® Annular Space or Vault Sensor. Model: LS3 ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD 2000 ® Mechanical Line Leak Detector. Model: RJ XLP ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: El Other(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: ❑ Piping Sump/Trench Sansone). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 110 OCT/KEROSENE Dispenser ID: ® Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(a), ❑ 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 Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(a). Dispenser ID: Dispenser ID: ❑Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). .If the facility contains more tanks or dispensers,copy this form. 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): Ed Steams Signature: Certification No.: A31048 License No: Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 STREET GALT,CA 95632 Date of Testing/Semwng. 317/16 Monitoring System Certification Page 1 of 4 2/21/07