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Appendix VI RECEIVED MONITORING SYSTEM CERTIFICATION SEP 17 2018 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 mustMMENTAL each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to th�m owner/operator.The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 3MIciL it ii, ARTAAENT A. General Information Facility Name: PACIFIC SERVICE STATION Bldg.No.: Site Address: 6131 PACIFIC AVENUE city: STOCKTON zip: 95207 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring system: VEEDER ROOT SMPLICITY Date of Testing/Servicing: 8/28/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific a ui ment inspect Iserviced: Tank ID: 87 OCT Tank Size: 12 K Tank ID: Tank Size: ® In-Tank Gauging Probe. Model: M A G I ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 3 0 3 ❑ Annular Space cr Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 3 5 2 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Seneor(s). Model: ❑ Fill Sump Sensor(s). Model: D 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: ❑ 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: DIESEL Tank Size: 12 K Tank ID: 91 OCT Tank Size: 12 K ® In-Tank Gauging Probe. Model: M A G I ® In-Tank Gauging Probe. Model: M A G I ® Annular Space or Vault Sensor. Model: 3 0 2 ® Annular Space or Ve ult Sensor. Model: 3 0 3 ® Piping Sump/Trench Sensor(s). Model: 3 5 2 ® Piping Sump/Trench Sensor(s). Model: 3 5 2. ❑ 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: P L L D - 8 4 8 4 ® Electronic Line Leak Detector. Model: P LLD- 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). Dispenser ID: I / 2 Dispenser ID: 3 / 4 ❑ 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 Chants). Dispenser ID: 5 / 6 Dispenser ID: 7 / 8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensogs). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Flcet(s)and Chain(s). ® Dispenser Containment Floats)and Cham(s). DispenserlD: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chairi ❑ 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 Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 2n°STREET GALT,CA 95632 Data of Testing/Servicing: 8/28/2018 Monitoring System Certification Pagel of4 2/21/07