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t 0 } Appendix VI 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, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for1 214 each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system APR 2 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 ENVIRONMENTAL HEALTH Facility Name: WATERLOO SHELL Bldg. No.: DEPARTMENT Site Address: 4315 E WATERLOO RD City: STOCKTON CA Zip: Facility Contact Person: RUPI Contact Phone No.: (209) 814-5576 Make/Model of Monitoring System VEEDER ROOT TLS 350 B. Inventory of Equipment Tested/Certified Check the aoorooriate boxes to indicate snecific eauinment insnertPd/sPrvirPd- Date of Testing/Servicing: 4-3-2014 Tank ID: 87 OCT Tank ID: 91 OCT ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 302 ® Annular Space or Vault Sensor. Model: 302 ® Piping Sump / Trench Sensor(s). Model: 2_08 304 ® Piping Sump / Trench Sensor(s). Model: 208 304 ® Fill Sump Sensor(s). Model: 2U8 304 ® Fill Sump Sensor(s). Model: 323 304 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD ❑ Model: ❑ 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 ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump /Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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 Dispenser ID: 5-6 ® Dispenser Containment Sensor(s), Model: 208 AND 304 ® Dispenser Containment Sensor(s). Model: 208 AND 304 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 AND 304 ® Dispenser Containment Sensor(s). Model: 208 AND 304 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID. VENT SUNIF Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: 208 AND 304 Sensor(s). Model: ❑ ShearValve(s). Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). -IT the tacmty contains more tanks or dispensers, copy this torm. maude inrormation Tor every tanK ana dispenser at the Tacmty. 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 apptv): ® System set-up ® Alarm history report Technician Name (print): DAVE WINKLER Signature: Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 4162 ISTREET GALT, CA 95632 Date of Testing/Servicing: 4-3-14 Monitoring System Certification Page 1 of 4 2/21/07 1 0