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• RECEIVE[ Appendix VI NOV 04 2015 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&W"NMENTAL HFA1Tu nFonanu;:NT This form must be used to document testing and servicing of monitoring equipment A separate certification or report must be prepared for each monitonng system control panel by the technician who performs the work.A copy of this forth 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 Name: WINE COUNTRY 76 Bldg.No.: Site Address: 1111 E KETTLEMAN LANE City: LODI CA Zip: 95240 Facility Contact Person: Sa deep Singh(Sunny) Contact Phone No.: (209)3694633 Make/Model of Monitoring System: VEEDER ROOT EMC Date of Testing/Servicing: 10/912016 B. Inventory of Equipment Tested/Certified Check the amorortriate boxes to indicates ecific equipment ins ectedlserviced: Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: ® In-Tank Gauging Probe. Model: MAG 2 ® In-Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump/Trench Sensorial. Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99LD 2000 ® Mechanical Line Leak Detector. Model: 99LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill I 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). Tank ID: DIE Tank Size: TanklD: Tank Size: ® In-Tank Gauging Probe. Model: MAG 2 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: SPLIT W 91 ❑ 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: 99LD2000 ❑ 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: 6-6 ❑ 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: 3-4 Dispenser ID: 7-8 ❑ 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 ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Floats)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 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 Thar apply): ®System set-up ®Alarm history reportt.\ Technician Name(print): David Winkler Signature: \f �_) Certification No.: 5263373-UT License No: Y018-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)7440112 Testing Company Address: 416 2"^STREET GALT,CA 95632 Date of Testing/Servicing: 10-9-2015 Monitoring System Certification Page 1 of 4 2/21/07