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R Er-Z7 EIVED Appendix VI FEB 14 2017 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,CaENO W"PEOPEALTH This form must be used to document testing and servicing of monitoring equipment.A separate certification or report rri �8 ENT each monitoring system control panel by the technician who performs the work.A copy of this form must be provided t t n s t 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: M C M 14 AM/PM Bldg.No.: Site Address: 130 S. WILSON WAY City: STOCKTON Zip: 95205 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 1/24/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 Tank Size: MASTER Tank ID: 87 Tank Size: SLAVE N In-Tank Gauging Probe. Model: M A G 1 N In-Tank Gauging Probe. Model: MAG I N Annular Space or Vault Sensor. Model: 4 0 7 N Annular Space or Vault Sensor. Model: 4 0 7 N Piping Sump/Trench Sensor(s). Model: 3 2 3 N Piping Sump/Trench Sensor(s). Model: 3 23 N Fill Sump Sensor(s). Model: 32 3 N Fill Sump Sensor(s). Model: 3 2 3 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: N Electronic Line Leak Detector. Model: P L L D - 8 4 8 4 N Electronic Line Leak Detector. Model: TURBINE OFF ❑ 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 Size: Tank ID: 91 Tank Size: ❑ In-Tank Gauging Probe. Model: N In-Tank Gauging Probe. Model: MAG 1 ❑ Annular Space or Vault Sensor. Model: N Annular Space or Vault Sensor. Model: 407 ❑ Piping Sump/Trench Sensor(s). Model: N Piping Sump/Trench Sensor(s). Model: 3 2 3 ❑ Fill Sump Sensor(s). Model: N Fill Sump Sensor(s). Model: 3 2 3 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: N Electronic Line Leak Detector. Model: P L L D - 8 4 8 4 ❑ 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 N Dispenser Containment Sensor(s). Model: 3 2 3 N Dispenser Containment Sensor(s). Model: 3 2 3 N ShearValve(s). N 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 N Dispenser Containment Sensor(s). Model: 3 2 3 N Dispenser Containment Sensor(s). Model: 3 2 3 N ShearValve(s). N ShearValve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: VENT SUMP Dispenser ID: ❑Dispenser Containment N Dispenser Containment Sensor(s). Model: 3 2 3 Sensor(s). Model: ❑ ShearValve(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 for every tank and dispenser at the facility. 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): N 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: 416 2nd STREET GALT,CA 95632 Date of Testing/Servicing: 1/24/2017 Monitoring System Certification Page 1 of 4 2/21/07