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l Appendix VI RE'CEI'VE® MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California jOg1 213 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Re 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 ENVIRONMENTAL HEALTH 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. PERMIT/SERVICES A. General Information Facility Name: Site Address: Facility Contact Person FOOD MART 2185 EAST FREMONT ROAD LAL Bldg. No.: City: STOCKTON Zip: 95205 _ Contact Phone No.: (209) 547.1700 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 9123/2013 R Inventory of Eauioment Tested/Certified Check the appropriate boxes to indicate specmc equipment rnsprctCurael vivu— TanklD: 87 Tank ID: 91 ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annuiar Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: LD 2000 ® Mechanical Line Leak Detector. Model: PE PETRO ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model. Other equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). ❑ (specify Tank ID. DIE Tank ID: ❑ In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model. ® Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: PE PETRO ❑ Mechanical Line Leak Detector. Model: ..] Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Tank Overfill / High -Level Sensor. Model: [I Tank Overfill / High -Level Sensor. Model: E] Other (specify equipment type and model in Section E on Page 2). C]Other (specify equipment type and model in Section E on Page 2). DispenserlD: 1-2 Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® 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: 208 ® Dispenser Containment Sensor(s). Model: 208 ® 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 ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). +-I, rl riicnoncar at The facility. "If the facility contains more ianKs or aispcnsu a, wNy C. Certification - I certify that the equipment identified in this document was inspectedlserviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verity 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): FELIX RAMIREZ Signature Certification No.: 834976 License No: 5273934 -UT 08-1740 OTTL Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 Z STREET GALT, CA 95632 Date of Testing/Servicing: 09-23-13 Monitoring System Certification Page 1 of 4 2/21/07 () 0 C t V.- i V-, C"k