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Appendix VI DIED MONITORING SYSTEM CERTIFICATION2097 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 form must be used to document testing and servicing of monitoring equipment.A separate certification or repA UvvN d 4 HE-TH each monitoring system control panel by the technician who performs the work.A copy of this form must be provided tA� K W§"VICES 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: DELTA ARCO Bldg.No.: Site Address: 440 W CHARTER WAY City STOCKTON Zip: 95206 Facility Contact Person: MAJOR Contact Phone No.: (209)465-2487 Make/Model of Monitoring System: VEEDER ROOT 350 Date of Testing/Servicing: 08-30-17 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecific a ui ment ins ected/serviced: Tank ID: 87 Tank ID: 91 Z In-Tank Gauging Probe. Model: MAG 1 Z In-Tank Gauging Probe. Model: MAG 1 Z Annular Space or Vault Sensor. Model: 420 Z Annular Space or Vault Sensor. Model: 420 Z Piping Sump/Trench Sensor(s). Model: 208 Z Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: 99 LD 2000 Z Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model: FLAPPER Z Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ 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. Madel: ❑ 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: 3-4 Z Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model 208 Z 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 Z Dispenser Containment Sensor(s). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 Z Dispenser Containment Sensor(s). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z 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): Z System set-up ®Alarm history report Technician Name(print): FELIX RAMIREZ Signature: .1/.r _ > i Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date of Testing/Servicing: 08-30-17 Monitoring System Certification Page 1 of 4 2/21/07