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t , Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California VC Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16, Division 3,Title 23,California Code ar�PR �7 018 t(� Regulations ` '� This form must be used to document testingand servicing of monitoring equipment.A se separate certification or re ort must be re ared.for^'�)� 9 9PP n P 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. !TAVIit=NT A. General Information Facility JSKS -MAIN ST ARCO Bldg.No.: Site 1100 S MAIN ST MANTECA Address City: zip: PFacility erson,Contact JESSE Contact Phone No.: (209)825-6784 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 3/1 212 01 8 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 Tank Size: Tank ID: 89 Tank Size: ® In-Tank Gauging Probe. Model: MAG-7 ® In-Tank Gauging Probe. Model: MAG-1 ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 323 ® Fill Sump Sensor(s). Model: 323 ® Fill Sump Sensor(s). Model: 323 ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: STP-MLD-G ❑ 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: 91 Tank Size: Tank ID: Tank Size: ® In-Tank Gauging Probe. Model: MAG-1 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 323 ❑ Piping Sump/Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 323 ❑ Fill Sump Sensogs). Model: ® Mechanical Line Leak Detector. Model: STP-MLD ❑ 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). Dispenser ID: 1-2 DispenserlD: 3-4 ® 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). DispenserlD: 5-6 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 I D: 9-10 Dispenser ID: 11-12 ®Dispenser Containment ® Dispenser Containment Sensor(s). Model: 323 Sensor(s). Model: 323 ® 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): ®System set-up ®Alarm history report Technician Name(print): Ed Steams Signature: Certification No.: A31048 License No: Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2"d STREET GALT,CA 95632 Date of Testing/Servicing: 3/12/18