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Appendix VI RECEIVED MONITORING SYSTEM CERTIFICATION FEB 17 201 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 CoCI&WR®NMENTAL HEALTH Regulations PERMIT/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 K1 WIGHT COLLINS AM/PM Site Addraac 130 S. WILSON WAY City: STOCKTON Bldg. No.: 82695 Zip: 95205 Facility Contact Parcnn LAWRENCE Contact Phone No.:2( 09) 436-6633 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/SE!rvicing: 1/19/2011 B. Inventory of Equipment Tested/Certified Check the aDDroDriate boxes to indicate specific equipment inspected/serviced: (Tank ID: 87 Model: MAGI ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 _ ® Piping Sump / Trench Sensor(s). Model: 323 ® Fill Sump Sensor(s). Model: 323 ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1/2 _ ® Dispenser Containment Sensor(s). Model: 323 ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 ® Dispenser Containment Sensor(s). Model: 323 _ ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: VENT SUMP ® Dispenser Containment Sensor(s). Model: 323 ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Tank !D: 87 SLAVE ® In -Tank Gauging Probe. Model: MAGI ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump / Trench Sensor(s). Model: 323 ® Fill Sump Sensor(s). Model: 323 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: 91 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump/ Trench Sensor(s). Model: 323 ® Fill Sump Sensor(s). Model: 323 ❑ Mechanical Line Leak Detector. Model: _ ® Electronic Line Leak Detector. Model: PLLD ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 3/4 ® Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). 323 Dispenser ID: 7/8 ® Dispenser Containment Sensor(s). Model: 323 ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). If the facility contains more tanks or dispensers, copy this form. Include Information Tor every and dispenser at the 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): ❑ System set-up ❑ Alarm history report Technician Name (print): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 4162 nSTREET GALT, CA 95632 Date of Testing/Servicing: 1/19/11 Monitoring System Certification Page 1 of 4 2/21/07