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VI RE 7 �..- r' • Appendix VI • �'r L_D: MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23,California Code of Regulations F_Srvl•:;:,rv:�';LtAi. FII!l�H This form must be used to document testing and servicing of monitoring equipment.A separate certification or report muFkpq.Mperap.feFiR,�,� each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank sy�s am 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 Name: MY MINI MART Bldg.No.: Site Address: 1756 N WILSON WAY City: STOCKTON Zip: 95205 Facility Contact Person: SINGH Contact Phone No.: (775)421.9978 Make/Model of Monitoring System: INCON 1001 Date of Testing/Servicing: 06-29-17 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins ected/serviced: Tank ID: 87 TanklD: 91 ® In-Tank Gauging Probe. jModel:el: MAG ® In-Tank Gauging Probe. Model: MAG ® Annular Space orVault Senel: ELS ® Annular Space or Vault Sensor. Model: ELS ® Piping Sump/Trench Sensel: ULS ® Piping Sump/Trench Sensar(s). Model: ULS ❑ Fill Sump Sensor(s). el: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detedel: 99 LD 2000 ® Mechanical Line Leak Detector. Motlel: 99 LD 2000 ❑ Electronic Line Leak Detecdel: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill/High-Level Sdel: FLAPPER ® Tank Ovefill/High-Level Sensor. Model: FLAPPER ❑ Other(specify equipment tin Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). TanklD: TanklD: L In-Tank Gauging Probe. Model: [IIn-TankGauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Ell,'Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: [I Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overall/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 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chaina). ❑ 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 Float(s)and Chain(s)- ❑DlSpa at Containment Float(s)and Chain(s). 'If the facility contains more tanks or dispensers,copy this fort;. Include information for every tank antl dispenser at the facility. E C E �®0�" I I�b C.Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' 4@ 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 attachedf tb 0 3 2017 copy of the report;(check all that apply): ®System set-up ®Alami history report U J L f Technician Name(print): FELIX RAMIREZ Signature: e'NVIRIONMEWAL FW-NJ•I Certification No.: 5273934-UT License No: 08-1740 -R*'J=4 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: M62 nd STREET GALT CA 95632 Date of Testing/Servicing: 06-29-17 Monitoring System Certification Page 1 of 4 2/21/07 - Is"k I&V