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RECENED Appendix VI JUN 1 2018 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Californiae tl1 TAL Authority Cited:Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23,California Code�of•Re`a'QW9 This form must be used to document testing and servicing of monitoring equipment.A separate certification or report musk{ieprepared 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: J & L MARKET Bldg.No.: Site Address: 8125 S. ELDORADO ST. City: FRENCH CAMP Zip: 95231 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 5/30/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 OCT Tank Size: 12 K Tank ID: Tank Size: S In-Tank Gauging Probe. Model: M A C1 I ❑ In-Tank Gauging Probe. Model: S Annular Space or Vault Sensor. Model: 4 2 0 ❑ Annular Space or Vault Sensor. Model: S Piping Sump/Trench Sensor(s). Model: 2 0 8 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: S Mechanical Line Leak Detector. Model: R J - F X - I V ❑ 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: DIESEL Tank Size: 6 K Tank ID: 91 OCT Tank Size: 6 K S In-Tank Gauging Probe. Model: M A G I ® In-Tank Gauging Probe. Model: M A G I S Annular Space or Vault Sensor. Model: 4 2 0 ® Annular Space or Vault Sensor. Model: SHARED W/ DSL S Piping Sump/Trench Sensor(s). Model: 2 0 8 ® Piping Sump/Trench Sensor(s). Model: 2 0 8 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: S Mechanical Line Leak Detector. Model: LD 2000 S Mechanical Line Leak Detector, Model: LD 2000 ❑ 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: I / 2 Dispenser ID: 3 / 4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). S Dispenser Containment Float(s)and Chain(s). S Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5 / 6 Dispenser ID: 7 / 8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: S Shear Valve(s). S Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). S Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ 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). '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): S 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)744-0112 Testing Company Address: 4162 Id STREET GALT,CA 95632 Date of Testing/Servicing: 5/30/2018 Monitoring System Certification Page 1 of 4 2/21/07