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1 10 Appendix VI RECEI V EC MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California MAY 2 7 2015 Authority Cited: Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23,California Code of Regu atlons This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must betENWRONMENTAL each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the owner/operator.The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30 days of 1ewQUET4 nC000714CNIT A. Ge rel Information Fa ility Name: SYSTEM TRANSPORT Bldg.No.: Si Address: 707 EAST ROTH City: FRENCH CAMP Zip: 96237 Fa ility Contact Person: SAM Contact Phone No.: (209)983-8664 M kelModel of Monitoring System: VEEDER ROOT TLS 300C Date of Testing/Servicing: 05-15-15 B. It ventory of Equipment Tested/Certified Check ff e apgropriate boxes to Indicatespecific equipment ins acted/serviced: Tank ID: DIESEL Tank ID: ® lin-Tank Gauging Probe. Model: MAG 2 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 407 ❑ Annular Space or Vault Sensor. Model: ® Piping Su p/Trench Sanatoria). Model: 208 ❑ Piping Sump/Trench Sansone). Model: ❑ Fill Sumpensor'a), Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model; ® Tank Ove II/High-Level Sensor. Model: FLAPPER ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(sp ify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). TanklD: TanklD: ❑ 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 Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensors). Model: ❑ Fill Sump Sensoria). Model: ❑ Mechanical i Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Cine Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(spe(ify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). DispenserI : 1 SAT Dispenser ID: 1-2 ® Dispenser Containment Sansone). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valv (a). ® Shear Valve(s). ❑ Dispenser Containment Fioat(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser I : 2 SAT Dispenser ID: ® Dispenser Containment Sansone). Model: 208 ❑ Dispenser Containment Seasons). Model: ® Shear Valy (s). ❑ ShearVelve(s). ❑ Dispenser ontainment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Cl in(s). Dispenser 10: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sansone). Model: Sanatoria). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chaints). 'If the facility c ntains 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' s. guidelineA ched 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): FELIX RAMIREZ Signature: Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 STREET GALT,CA 95632 Date of Testing/Servicing: 05-15-15 Monitoring System Certification Page 1 of 2/21/07