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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 tone must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring 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 copy of this forth to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: E.F.KLUDT AND SONS CARDLOCK Bldg.No.: Site Address: 1126 E.PINE ST City: LODI Zip: 96240 Facility Contact Person: STEVE Contact Phone No.: (209)368-0634 Make/Model of Monitoring System: VEEDER ROOT TLS-360 Date of Testing/Servicing: 4-7-16 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equi ment ins ected/serviced: F20-K CLEAR DIESEL Tank 10-K RED DIESEL Tank Size: Tank1,1SD: Size: Tank ID: auging Probe. Model: MAG-1 ® In-Tank Gauging Probe. Model: MAGI pace or Vault Sensor. Madel: 420 ® Annular Space or Vault Sensor. Model 420 mp/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Motlel: 208 Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: al Line Leak Detector. Model: 99 LO 2000 ® 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). iiii- 1 OK RED DIESEL SYPHON Tank Tank ID: Size: Tank ID: Tank Size: ® In-Tank Gauging Probe. Model: MAGA [IIn-TankGauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: IR Piping Sump/Trench Sensoria). Model: 208 ❑ 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: t1htronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: k Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: r(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). ser ID: 7/8 DispenserID: 9110 enser Containment Sensor(a). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 r Valve(s). ® ShearValve(s). enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). ser ID: 9SAT DispenserID: 10SAT/11SAT enser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208r Valve(s). ® ShearValve(s). enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Cham(s). DispenserlD: 11/12 Dispenser ID: ❑ Dispenser Containment ® Dispenser Containment Sensoria). Model: 208 Sensor(s). Model: ® Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)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(pant): Ed Steams Signature: _ Certification No.: A31048 License o. Testing Company Name: AFFORDA-TEST Phone No. _L209)744-0113 Testing Company Address: 416 2 STREET GALT,CA 96632 Date of Testing/Servicing: 4!//16 Monitoring System Certification Page l of 4 2/21/07 LLL�La 11114., MAY 0 2 2016 .brr