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RECEIVED Appendix VI APR i 8 2018 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safe riCode; Chapter 16, Division 3, Title 23, California Code oD =RNTTMAELRHA� This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared 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: Site Address: Facility Contact Person: WATERLOO SHELL 4315 E. WATERLOO RD. RUPI Make/Model of Monitoring System: VEEDER ROOT TLS -350 City: Bldg. No.: STOCKTON B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Contact Phone No.: Zip: 95205 Date of Testing/Servicing: 4/10/2018 Tank ID: 87 OCT Tank Size: 15 K Tank ID: 91 OCT Tank Size: 12 K ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 3 0 2 ® Annular Space or Vault Sensor. Model: 3 0 2 ® Piping Sump/ Trench Sensor(s). Model: 2 0 8 ® Piping Sump / Trench Sensor(s). Model: 2 0 8 ® Fill Sump Sensor(s). Model: 2 0 8 ® Fill Sump Sensor(s). Model: 2 0 8 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: P L L D- 8 4 8 4 ® Electronic Line Leak Detector. Model: P L L D- 8 4 8 4 ❑ 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: Tank Size: Tank ID: Tank Size: ❑ 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: hanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: LEDElectronic k Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) r (specify equipment type and model in Section E on Page 2). Dispenser ID: I / 2 Dispenser ID: 3 / 4 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5 / 6 Dispenser ID: 7 / 8 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(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): ® System set-up ® Alarm history report Technician Name (print): ZANE NIMMO Certification No.: A28446 Testing Company Name: AFFORDA-TEST Testing Company Address: 416 2nd STREET GALT, CA 95632 Signature: License No: 04-1676 Phone No. (209) 744-0112 Date of Testing/Servicing: 4/10/2018 Monitoring System Certification Page 1 of 4 2/21/07