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Appendix VI HE VEI� EL,, MONITORING SYSTEM CERTIFICATION A\p/ �/C nia Authority Cited: Chapter 6.7, Health and rSafety Code;Use By All 6Chapter 16ons ,Division 3the state f Title 23,California Code of Aggalic&2015 be used document and servicing of This monitoring isystem control panel by Ne technician who Performs gthe work.A copy of hequipment A is form gmust be provitled tcation or re if o lh d r owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 NMENTAL A. General Information nCOAOTIk CAIT 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: 416/2016 B. Inventory of Equipment Tested/Certified Check the a ro date boxes to indicates ecifiC equipment inspected/serviced: 20-K CLEAR DIESEL Tank 10-K RED DIESEL Tank ID: Size: Tank ID: Tank Size: ® In-Tank Gauging Probe. Model: MAGA ® In-Tank Gauging Probe. Model: MAG1 ® Annular Space or Vault Sensor Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump/Trench Sansone). Model 208 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: El 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 modal in Section E on Page 2), 10K RED DIESEL SYPHON Tank Tank ID: Size: Tank ID: Tank Size: ® In-Tank Gauging Probe, Model: MAG-1 ❑ In-Tank Gauging Probe, Motley ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Seasons). Motley ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Motlel: C) Mechanical Line Leak Detector. Model: E] Electronic Line Leak Detector. Model. ❑ Electronic Line Leak Detector. Model: C1 Tank Overall/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model ❑ Other(specify equipment type and model in Section E on Page 2). 1 ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 7/8 Dispenser ID: 9110 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sansone), Model: 208 ® Shear Valve(s). ® Shear Velve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: 9-SAT Dispenser ID: 10 SAT/11 SAT ® Dispenser Containment Sansone). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® ShearValve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). DispenserlD: 11/12 Dispenser ID: E] Dispenser Containment ® Dispenser Containment Sensor(s). 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 verity 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;felieck all that apply): to System set-up ®Alarm history report Technician Name(print): Ed Steams Signature: Certification ume: License No: Testing Company Name. AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 STREET GALT CA 96832 Date of Testing/Servicing: 4AVI b Monitoring System Certification Page 1 of 4 2/21/07