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no 7,�V- Appendix VI FEB 16 t0 i0 MONITORING SYSTEM CERTIFICATIOhL�4VIR(J,%t,,,Lt\,T HEALTH 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, Calif 6%4&kn Y ICtS 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 NnmP' WIGHT COLLINS ARCO AMIP Site AddrPcs• 130 S. WILSON WAY Facility Contact PPrsnn, LAWRENCE Make/Model of Monitoring System: VEEDER ROOT TLS 350 City: STOCKTON Bldg. No.: 82695 Zip: 95205 Contact Phone No.: B. Inventory of Equipment Tested/Certified r`knrL fl- � — A�in t,^wm& fn ,nAi—+n ann Mi nn„inmPn4 inenPr•tarl/CPrvirPrt' Date of Testing/Servicing: 1/21/2010 Tank ID: 87 Tank ID: 87 SLAVE ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe, Model: MAG 1 ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ 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). Tank ID: Tank ID: 91 ® In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ 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 ❑ 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: 516 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: 9/10 Dispenser ID: 11/12 ❑ 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). 'If the facility contains more tanks or dispensers, copy this form. Include intormation tor every ianK ano aispenser at Tne TaCHITy. 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 Certification No.: A28446 Testing Company Name: AFFORDA-TEST Testing Company Address: 416 2" STREET GALT, CA 95632 _ Monitoring System Certification Signature: License No: 04-1676 Phone No. (20 9) 744-0113 Date of Testing/Servicing: 1/21/10 Page 1 of 4 2/21/07