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Appendix VI 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 This form 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. A. General Information Facility Name: CITY OF LODI Bldg, No.: Site Address: 1331 S HAM LANE City: LODI Zip: 95240 Facility Contact Person: RANDY Contact Phone No.: (209) 333-6830 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 09-16-16 B. Inventory of Equipment Tested/Certified Tank lD. 87 TankID: 87 ® In -Tank Gauging Probe. Model: MAGI M 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 Senson(s). Model: 208 ❑ 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: 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: DIESEL Tank ID: ® 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: ❑ FIII Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector, Model: PE PETRO ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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: ® Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: ® Shear Vatve(s). ❑ Shear Vatve(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 Sensogs). Model: ❑ Shear Vatve(s). ❑ Shear Vatve(s). ❑ Dispenser Containment Floaqs) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shearvalve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). .. ..._.__....�.............. ....ry ---,,. r,,.e..uo.1- ,nwwn,an every m, m a, n, wa�anam at u W rat:mry. C. Certification -1 certify that the equipment identified In this document was inspected/serviced In accordance with the manufacturers' guidelines. Attached to this Certlficatlon 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): FELIX RAMIREZ Signature: Certification No.: 52739344JT License No: 08-1740 Testing Company Name: AFFORDA•TEST Phone No. (209) 744-0113 Testing Company Address: 416 2n° STREET GALT, CA 95632 Date of Testing/Servicing: 09-16-16 Monitoring System Certification Page 1 of 4 2/21/07