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RECEIVED Appendix VI OCT 2 2 2019 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Califomia Authority Cited:Chapter 6.7,Health and Safety Code; Chapter 16,Division 3,Title 23,CalifcL7j g@N%*[l APa6sHEAJH This form must be used to document testing and servicing of monitonng equipment.A separate certification or report must p ff,,A RTMEN I each monitoring system contml panel by the technician who performs the work.A copy of this form must be provided to the tan 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 Fatuity Name: FLAG CITY CHEVRON Bldg.No.: Site Address 6421 CAPITOL AVENUE Corr: LODI, CA zip: 95240 Facility Contact Person: Contact Phone.No.: ( ) Make/Madel of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 9/26/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspect /sewiced; Tank ID: 91 OCT Tank Size: 12 K Tank ID: 87 MAIN Tank Size: 10 K H In-Tank Gauging Probe. Model: M A G I E In-Tank Gauging Probe. Model: M A G I E Annular Space or Vault Sensor. Model: 4 0 9 E Annular Space or Vault Sensor. Model: 4 0 9 H Piping Sump/Trench Senors). Model: 2 0 8 E Piping Sump/Trench Sensor(s), Model: 4 0 9 H Fill Sump Sensor(s). Model: 2 0 8 H Fill Sump Sensor(s). Model: 2 0 8 E Mechanical Line Leak Detector. Model: 99 LD 2000 E Mechanical Line Leak Detector. Model: 99 LD 2000 D Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: D Tank Overfill/High-Level Sensor, Model: D 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 AUX Tank Size: 10 K Tank ID: DIESEL Tank Size: 10 K H In-Tank Gauging Probe. Model: M A G I. E In-Tank Gauging Probe. Model: M A G 7 H Annular Space or Vault Sensor. Model: 4 0 9 H Annular Space or Vault Sensor. Model: 4 0 9 E Piping Sump/Trench Sensor(s), Model: 2 0 8 H Piping Sump/Trench Sensor(,). Model: 2 0 8 E Fill Sump Sensor(s). Model: 2 0 8 H Fill Sump Sensor(s). Model: 2 0 8 H Mechanical Line Leak Detector. Model: 99 LD 2000 H Mechanical Line Leak Detector. Model: 99 LD 2000 D Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: D Tank Overfill/High-Level Sensor. Model: D Other(specify equipment type and model in Section E on Page 2). D Other(specify equipment type and model in Section E on Page 2). Dispenser ID: I / 2 Dispenser ID: 3 / 4 E Dispenser Containment Sensor(s). Model: 2 0 8 H Dispenser Containment Sensor(s). Model: 2 0 8 H Shear Valve(s). E Shear Valve(s). D Dispenser Containment Float(s)and Chain(s). D Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5 / 6 DispenserlD: 7 / 8 E Dispenser Containment Sensor(,). Model: 2 0 8 H Dispenser Containment Sensor(s). Model: 2 0 8 H Shear Valve(,). E Shear Valve(s). ❑ Dispenser Containment Float(,)and Chain(s). D Dispenser Containment Flmgs)and Chain(s). DispenserlD: 9 / 10 & 11 / 12 DispenserlD: VENT SUMP E Dispenser Containment Sensor(s). Model: 2 0 8 (X2) H Dispenser Containment Sensor(s), Model: 2 0 8 E Shear Valve(s). ® Shearvalve(s). D Dispenser Containment Float(s)and Chaln(s). D Dispenser Containment Floats)and Chain(s). -if the facility contains more tanks or dispensers,copy this form. Include infornation 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(,.a.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): 7ANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 2"d STREET GALT,CA 95632 Date of Testing/Ser fling: 9/26/2018 Monitoring System Certification Page 1 of 4 2/21/07