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KtL;tivtL) • Appendix VI JUL 11 2011 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of C$fdtflNONMENTAL HEALTH Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title JEFOAf19GMK�W of Regulations This form 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 a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility SYSTEM TRANSPORT Bldg.No.: ue�e site 707 E. ROTH RD. city: FRENCH CAMP zip: 95231 Anrlrp.%' Facility Contact perenn. Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 300 C Date of Testing/Servicing: 5124/2011 B. Inventory of Equipment Tested/Certified Check theappropriate boxes to indicate specific equipment ins ec[ed/serviced: 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 I 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 Overall/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specifyequipment type and model In Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: DI Tank Size: Tank ID: Tank Size: ® In-Tank Gsugi g 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 Sensor(s). 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 Q Tank Overfill ll High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(sped 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 SATELITE Dispenser ID: MAIN DISP ® Dispenser Col tainment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model 208 ® Shear Valve( . ® Shear Velvets). ❑ Dispenser Coy talnment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chaln(s). Dispenser ID: ! 2 SATELITE Dispenser ID: ® Dispenser Cctalnment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: ® Shear Valve(Itainment . ® Shear Velve(a). ❑ Dispenser Co Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: DlspenserlD: ®Dispenser Containment ® Dispenser Coltainment Sensor(s). Model: Sensor(s). Model: ® shear Valve(y). ®Shear Valve(s). ❑ Dispenser Co'tainment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). 'If the facility con ins 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 Planhowing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a copy of the reps rt;(check all Nmr apply): ®System set-up ®Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No. A28446 License No: 004-4-1878 Testing Comps V Name: AFFORDA-TEST Phone No. (209)744.0113 Testing Compal ----Adtlress: 418 2 STREET GALT,CA 95832 Date of Testing/Servicing: 5/24/11 Monitoring Sy Il tem Certification Page 1 of 4 2/21/07