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Appendix VI MONITORING SYSTEM CERTIFICATION RECEIVED /C® For Use By All Jurisdictions Within the State of California RE G 6_ Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for JUN 0 6 2014 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/operat r.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. GanerInformation ENVIRONMENTAL HEALTH Facili I Name: SYSTEM TRANSPORT Bldg.No.: PERMMSERVICES Site Address: 707 EAST ROTH City: FRENCH CAMP Zip: 95237 Facility Contact Person: SAM Contact Phone No.: (209)983-8654 MakelModel of Monitoring System: VEEDER ROOT TLS 300C Date of Testing/Servicing: 5-23-2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: DIESEL Tank ID: In-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 Sump Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Se sorts). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Lima Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill High-Level Sensor. Model: FLAPPER ❑ Tank Overfill l 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). TarklD: TarklD: ❑ 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 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 I High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(spi equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID:. 1 SAT Dispenser ID: 1-2 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear velvets). ® Shear Valve(s). ❑ Dispenser Containment Floats)and Chairi ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: 2 SAT Dispenser ID: • Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floatts)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). 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 Floats)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;(check all that apply): ❑System set-up ®Alarm history report Technician Na1'a(print): DAVE WINKLER Signature: r� Certification No. 5273934-UT License No: 06-11739 l) Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2" STREET GALT,CA 95632 Date of Testing/Servicing: 5-23.20014 Monitoring System Certification Pagel of 4 2/21/07 ��G