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0 Appendix VI _ _,L,,'4k MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California L T 5 2 01 J Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code o egu atlons This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be'preraifaVlbr jq' ' each monitoring system control panel by the technician who performs the work. A copy of this form must be provided,to the-flahksystBm Vw._ owner/operator. The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30 days of test date General Information Facility Name: ORLANDOS MARKET Bldg. No.: Site Address: 18754 LINDEN RD HWY 26 City: LINDEN Zip: 96236 Facility Contact Person: Make/Model of Monitoring System: VEEDER ROOT TLS 350 Contact Phone No.: (209) 887-1100 B. Inventory of Equipment Tested/Certified Check the aDDropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 7/12/2016 Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: N In -Tank Gauging Probe. Model: MAG -1 N In -Tank Gauging Probe. Model: MAG -1 N Annular Space or Vault Sensor. Model: 420 N Annular Space or Vault Sensor. Model: 420 N Piping Sump / Trench Sensor(s). Model: 208 N Piping Sump/ Trench Sensor(s). Model: 208 N Fill Sump Sensor(s). Model: 208 N Fill Sump Sensor(s). Model: 208 N Mechanical Line Leak Detector. Model: 99 LD 2000 N Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: N Tank Overfill / High -Level Sensor. Model: 90% N Tank Overfill / High -Level Sensor. Model: 90% ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank Size: Tank ID: Tank Size: N In -Tank Gauging Probe. Model: MAG -1 ❑ In -Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: N Piping Sump/ Trench Sensor(s). Model: 208 ❑ Piping Sump/ Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ 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: 1-2 Dispenser ID: 3-4 N Dispenser Containment Sansone). Model: 208 N Dispenser Containment Sensor(s). Model: 208 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s) and Chairi ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 ® Dispenser Containment N Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 N 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 me 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 thatthis 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 rhal apply): N System set-up N Alarm history report Technician Name (print): Ed Steams Certification No.: A31048 Testing Company Name: AFFORDA-TEST Testing Company Address: 416 2" STREET GALT, CA 95632 Monitoring System Certification Signature: n�2---- License No:! Phone No. (209) 744-0113 Date of Testing/Servicing: 7/12/16 Pagel of 4 2/21/07