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RECEIVED <br /> Appendix VI OCT 2 7 2Q16 <br /> MONITORING SYSTEM CERTIFICATION ENVIRO &IEN,� <br /> For Use By All Jurisdictions Within the State of California PCH STH <br /> S I <br /> Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23, California Code of a li <br /> This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for <br /> each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system <br /> 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. <br /> A. General Information <br /> Facility Name: WEST LANE CHEVRON Bldg.No.: <br /> Site Address: 4747 WEST LANE City: STOCKTON zip: 95210 <br /> Facility Contact Person: RINKU Contact Phone No.: ( ) <br /> Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 9/29/2016 <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicatespecific equipment inspected/serviced: <br /> Tank ID: 8 7 Tank Size: MIDDLE Tank ID: 87 Tank Size: E A ST <br /> E In-Tank Gauging Probe. Model: MAG 1 E In-Tank Gauging Probe. Model: MAG 1 <br /> E Annular Space or Vault Sensor. Model: 4 0 9 E Annular Space or Vault Sensor. Model: 409 <br /> E Piping Sump/Trench Sensor(s). Model: 2 0 8 E Piping Sump/Trench Sensor(s). Model: 2 0 8 <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> E Electronic Line Leak Detector. Model: P L L D E Electronic Line Leak Detector. Model: PLL D <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). <br /> Tank ID: Tank Size: Tank ID: 91 Tank Size: <br /> ❑ In-Tank Gauging Probe. Model: E In-Tank Gauging Probe. Model: MAG 1 <br /> ❑ Annular Space or Vault Sensor. Model: E Annular Space or Vault Sensor. Model: 409 <br /> ❑ Piping Sump/Trench Sensor(s). Model: E Piping Sump/Trench Sensor(s). Model: 2 0 8 <br /> ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> ❑ Electronic Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: P L L D <br /> ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: <br /> ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). <br /> Dispenser ID: I / 2 Dispenser ID: 3 / 4 <br /> E Dispenser Containment Sensor(s). Model: 2 0 8 E Dispenser Containment Sensor(s). Model: 2 0 8 <br /> E Shear Valve(s). E Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: 5 / 6 Dispenser ID: 7 / 8 <br /> E Dispenser Containment Sensor(s). Model: 2 0 8 E Dispenser Containment Sensor(s). Model: 2 0 8 <br /> E Shear Valve(s). E Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑ Dispenser Containment <br /> ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: <br /> ❑ Shear Valve(s). ❑Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> 'If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C.Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines.Attached to this Certification is information(e.g.manufacturers'checklists)necessary to verify that this information is correct <br /> and a Plot Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a <br /> copy of the report;(check all that apply): E System set-up E Alarm history report <br /> Technician Name(print): ZANE NIMMO Signature: <br /> Certification No.: A28446 License No: 04-1676 <br /> Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 <br /> Testing Company Address: 416 2n1 STREET GALT,CA 95632 Date of Testing/Servicing: 9/29/2016 <br /> Monitoring System Certification Page 1 of 4 2/21/07 <br />