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Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Slate of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23,California Code of Regulations This form must be used to document testing and servicing of monitodng 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 Name: GEORGE'S MINI MART Bldg.No.: Site Address: 18662 N. HWY 88 City: LOCKEFORD Zip: 95237 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitodng System: GILBARCO EMC Date of Testing/Servicing: 3-8-2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 Tank Size: Tank ID: 89 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 Sensors). Model: 205 ® Piping Sump/Trench Sensor(s). Model: 205 D Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Model: ID Mechanical Line Leak Detector. Model: g9k:2000 ® Mechanical Line Leak Detector. Model: STP-MLD D Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: D Tank Overfill/High-Level Sensor. Model: D Other(specify equipment type and model in Section E on Page 2). D Other(specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank Size: Tank ID: 91 Tank Size: ® In-Tank Gauging Probe. Model: MAG 2 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 M Annular Space or Vault Sensor. Model: Some as 89 Tank ® Piping Sump/Trench Sensor(s). Model: 205 ® Piping Sump/Trench Sensor(s). Model: 205 D Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Model ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: STP-MLD D Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: D Tank Overfill/High-Level Sensor. Model: D Other(specify equipment type and model in Section E on Page 2). D Other(specify equipment type and model in Section E on Page 2). DispenserlD: 1/2 DispenserlD: 3/4 D Dispenser Containment Sensor(s). Model: D Dispenser Containment Sensor(s). Model: ® ShearValve(s). ® Shear Velvets). ® Dispenser Containment Floats)and Cham(s). ® Dispenser Containment Float(s)and Chain(s). DispenserlD: 5/6 DispenserlD: 7/8 D Dispenser Containment Sensor(s). Model: D Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Velvets). ® Dispenser Containment Float(s)and Chaints). ® Dispenser Containment Float(s)and Chain(s). DispenserlD: 9/10 DispenserlD: 9 SATELITE & 10 SATELITE ❑Dispenser Containment D Dispenser Containment Sensor(s). Model: Sensor(s). Model: ® Shear Valve(s). ®Shear Valve(s). ® Dispenser Containment Float(s)and Charon s). ®Dispenser Containment Float(s)and Chain(s). 'If the facility contains more tanks or dispensers,copy this forth. 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 that apply): ®System set-up ®Alarm history report Technician Name(print): DAVE WINKLER Signature: W M f� U 1 Certification B34975 License No: 04-7676 V No.: Testing Company AFFORDA-TEST Phone No. (209)744-0113 Name: Testing Company Address: 416 2nO STREET GALT,CA 95632 Date of Testing/Servicing: 3-6-2016 Monitoring System Certification Page 1 of MAROW IAL 4�1M�4dA�IA6AIT