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ktl.Elv'r-v Appendix VI FEB 2 2��6 MONITORING SYSTEM CERTIFICATION EWRONMENTALHE&7H For Use By All Jurisdictions Within the State of California 'T Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California , o e O�eR" gufatl�on�s 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: Mcm14 ampm Site Address: 130 S WILSON WAY Bldg. No.: City: STOCKTON CA Zip: Facility Contact Person: LAWRENCE Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 1-12-2016 B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate snpcific enuinmpnt incnartad/carvirad- Tank ID: 871 Tank ID: 91 ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model': MAG 1 ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump I Trench Sensor(s). Model: 323 ® Piping Sump / Trench Sensor(s). Model: 323 ® Fill Sump Sensor(s). Model: 323 ® Fill Sump Sensor(s). Model: 323 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD El 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: 87 2 Tank ID: NA ❑ In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 323 ❑ Piping Sump I Trench Sensor(s). Modef: ® Fill Sump Sensor(s). Model: 323 ❑ Fill Sump Sensor(s). Model ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Mode(: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Modef: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill I 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: 5-6 ® Dispenser Containment Sensor(s). Model: 323 ® Dispenser Containment Sensor(s). Model: 323 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 323 ® Dispenser Containment Sensor(s). Model: 323 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: VENT SUMP Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: 323 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 information Tor every tanK and dispenser at the TacniTy. 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): DAVE WINKLER Signature: V�, ) Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2nd STREET GALT, CA 95632 Date of Testing/Servicing: 1-12*2016 Monitoring System Certification Page 1 of 4 S ,�C_ 2/21/07