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W-ULIA-U Appendix VI AUG 2 8 2015 MONITORING SYSTEM CERTIFICATION ENVIRONMENTALHEALTF� 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 ReggRNJ{SERVICES 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: FAST AND EASY SHELL Site Address: 1399 YOSEMITE AVE Facility Contact Person: DEEP Make/Model of Monitoring System: VEEDER ROOT Bldg. No.: City: MANTECA Zip: 95336 Contact Phone No.: (209) 823-3460 Date of Testing/Servicing: 06-11-15 B. Inventory of Equipment Tested/Certified Check the annronriate hnxes to indiratp cnprifir aniiinmant incnartarl/c—irael- Tank ID: 87 Tank ID: 91 E In -Tank Gauging Probe. Model: MAG E In -Tank Gauging Probe. Model: MAG 1 E Annular Space or Vault Sensor. Model: 303 E Annular Space or Vault Sensor. Model: 303 E Piping Sump / Trench Sensor(s). Model: 208 E Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model FX1V E Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: E Tank Overfill / High -Level Sensor. Model: FLAPPER E Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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: E In -Tank Gauging Probe. Model: MAGII ❑ In -Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model 303 ❑ Annular Space or Vault Sensor. Model: r P� 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: FX1V ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model. E 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: 3-4 E Dispenser Containment Sensor(s). Model: 208 E Dispenser Containment Sensor(s). Model: 208 E Shear Valve(s). E 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 E Dispenser Containment Sensor(s). Model: 208 E Dispenser Containment Sensor(s). Model: 208 E Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Fioat(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). ❑ Dispenser Containment Float(s) and Chain(s). -it the tacmty contains more tanks or dispensers, copy this rorm. incivae information for every tank ana dispenser at the racwry. 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): E System set-up E Alarm history report 'r Technician Name (print): FELIX RAMIREZ Signature: Certification No.: 5273934 -UT License No: 08-1740 Testino,:; ompany Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 06-11-14 Monitoring System Certification Page 1 of 4 2/21/07 W C