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Appendix VI MONITORING SYSTEMn!--- ME " ' �--' CERTIFICATION For Use By All Jurisdictions Within the State of California SUN G 9 LO f a Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23, California Code of Regulations ENVIRONMENT HEALTH This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for FERMI iT/SERl�lCE each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system ownerloperator.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 Faciity Name: J&L MARKET Bldg.No.: Site Address: 8125 S EL DORADO City: STOCKTON Zip: Facility Contact Person: EUGENIA Contact Phone No.: (209)982-0897 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 05-27-10 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tank ID: 91 ® I-i-Tank Ga�;c^y Prcbe. McdeC MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 Qi A^ -_,';ar Space or Vauft Senscr. Model: 420 M Annular Space or Vault Sensor. Model: 420 Pfoi7g Sump,Trench Serwr(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ F:;Sumo Se-^scr(s). Model: ❑ Fill Sump Sensor(s). Model: Mecf•ar''ca'Lire Leak Detector. Model: RED JACKET ® Mechanical Line Leak Detector. Model: LD 2000 OLD E'e_'-_-c--e Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Taric C'.et:. High-Leve:Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ O'.*=:,scec�.v egc cTer;type and.model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank ID: r ❑ :--T'a Ga-;-,Pr:t=. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: © A"- Sca:e cr Valft Sensor_ Model: 420 SPLIT W 91 ❑ Annular Space or Vault Sensor. Model: P S_-_ Tench Sersor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: Model: ❑ Fill Sump Sensor(s). Model: :_-_- ,ai -e Leak Detectcr Model LD 2000 OLD ❑ Mechanical Line Leak Detector. Model: Li,e Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: C.: `---'-eve:,Sensor. Model-, ❑ Tank Overfill/High-Level Sensor. Model: a-drrcdel in Section E on Page 2). i ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 - - [I Dispenser Containment Sensor(s). Model: S"= -r _- _•- •_- - , ® Shear Valve(s). F cars:__ Cha^i5 ® Dispenser Cortainment Float(s)and Chain(s). Dispenser ID 5-6 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ® ShearValve(s). __-= -est Floats)and Cha ms's;. ® Dispenser Containment Float(s)and Chain(s). Dispenser ID. Dispenser ID: ❑ Dispenser Containment D°seerser C.~a`"^ort Serxes;. Mode!: Sensor(s). Model: ❑ S^earVa:e s, ❑ Shear Valve(s). ❑ D sce-se-Cc-:a =-.== S - ❑ Dispenser Containment Float(s)and Chain(s). c-c'scarsers 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 inspectediserviced 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 Pian showing the layout of monitoring equipment.For any equipment capable of generating such reports,1 have also attached a COPY of the report,(check atf that apph•i: ❑System set-up ❑Alarm history report Tev.^_a-Narre;p mt;: FELIX RAMIREZ Signature: - Ce Hca" No-: 5273934-UT License No: 08-1740 -es"^c Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2" STREET GALT,CA 95632 Date of Testing/Servicing: 05-27-10 — - Monitoring System Certification Page 1 of 4 � 1