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a KtUEIVE® 0 JUL') 8 Appendix VI 2U10 MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL For Use By All Jurisdictions Within the State of Califomia PERM Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of RegUl� r$VI EES rN This toren 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 General Information Facility Name: ORLANDOS MARKET Bldg. No.: Site Address: 18754 LINDEN RD HWY 26 City: LINDEN Zip: 95236 Facility Contact Person: SAMMY Contact Phone No.: (209) 887-1100 Make/Model of Monitoring System: V EEDER ROOT TLS 350 B. Inventory of Equipment Tested/Certified ., r..._..e ... :..w�..�.e s.. e ni Date of Tesfing/Servicing: 7112/2016 -If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the racinry. 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 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): Ed Stearns Certification No.: A31048 Testing Company Name: AFFORDA-TEST Testing Company Address: 416 2n° STREET GALT, CA 95632 Signature: C<f _�--J%------ License No: Phone No. (209) 744-0113 Date of Testing/Servicing: 7/1216 Monitoring System Certification Page 1 of 4 2/21/07 Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: ® In -Tank Gauging Probe. Model: MAG -1 ® In -Tank Gauging Probe. Model: MAG -1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑Electronic Line Leak Detector. Model: ElElectronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: 90% ® 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: ® In -Tank Gauging Probe. Model: MAG -1 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 ❑ 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: 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). ❑ Omer (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model : 208 ® Shear Velvets). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Velve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chairi DispenserlD: 9-10 DispenserlD: 11-12 ® Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 ® Shear Valve(s). IR Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ 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 racinry. 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 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): Ed Stearns Certification No.: A31048 Testing Company Name: AFFORDA-TEST Testing Company Address: 416 2n° STREET GALT, CA 95632 Signature: C<f _�--J%------ License No: Phone No. (209) 744-0113 Date of Testing/Servicing: 7/1216 Monitoring System Certification Page 1 of 4 2/21/07