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Appendix VI HECEIVED MONITORING SYSTEM CERTIFICATION APR 16 2015 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 Cgrl�q(R�ylk�tipPgENTAL This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must blw,,,�/10r9�jlTgkl CNOg,DT�r T each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the ri 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)368-0634 Make/Model of Monitoring System: TL 350/ RONAN X76S Date of Testing/Servicing: 4/612015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific a ui ment ins ectad/serviced: Tank ID: KEROSENE Tank Size: Tank ID: 110 OCT Tank Size: N In-Tank Gauging Probe. Model: MAG-1 N In-Tank Gauging Probe, Model: MAGI N Annular Space or Vault Sensor. Model: LS3 N Annular Space or Vault Sensor. Model: LS3 N Piping Sump/Trench Sensoria). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: LD 2000 N Mechanical Line Leak Detector. Model: RJ XLP ❑ 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 Secton 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 Seraphs). Model: ❑ Piping Sump/Trench Sansone). Model: ❑ Fill Sump Sensors). Model: ❑ Fill Sump Sensoria). 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 OCTIKEROSENE Dispenser ID: N Dispenser Containment Sensoria). Model: 208 ❑ Dispenser Containment Sensor(s). Model: N 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 Sensors). Model: N Dispenser Containment Sensoria). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chairl Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Velvets). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chalri ❑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 Inspectedmervlced 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 thin apply): N System set-up N 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 Data of Testing/Servicing: 3/6/15 Monitoring System Certification Pagel of 4 2/21/07