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Appendix V1 MONITORING SYSTEM CERTIFICATION SEP 1 5 2010 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 COUNTY Regulations SAL each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system for certification or report must be prepared -IMENT This form must be used to document testing and servicing of monitoring equipment.A separate owner/operator,The owner/operator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date, A. General Information Facility KI.M. MARIGOLD SHELL Bldg.No.. Site Aricirpsm- 6131 PACIFIC AVE City: STOCKTON CA Zip: Facility Contact PAr.qnn- TRAN Contact Phone No.: Make/Model of Monitoring System VEEDER ROOT TILS 350 Date of Testing/Servicing: 8/17/2010 B. Inventory of Equipment Tested/Certified ---Check the appropriate boxes to indicate specific equipment Inspected/serviced: Tank ID- 87 Tank ID: 11 0 In-'rank Gauging Probe. Model: WAG 1 0 In-Tank Gauging Probe. Model. MAG I 0 Annular Space or Vault Sensor. Model: 302 0 Annular Space or Vault Sensor. Model 302 23 Piping Sump/Trench Sensor(s). Model: 352 0 Piping Sump/Trench Sensor(s). Model: 352 El Fill Sump Sensor(s). Model: - El Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model Electronic Line Leak Detector. Model: PLLD 0 Electronic Line Leak Detector. Model: PLLD ❑ Tank Overfill/High-Level Sensor. Model: [I Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2) El Other(specify equipment type and model in Section E on Page 2) Tank ID: DSL Tank ID: 0 In-Tank Gauging Probe. Model: MAG 1 [1 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 302 C] Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 352 0 Piping Sump/Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: - C-1 Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector. Model: E Electronic Line Leak Detector. Model: PLLD El Electronic Line Leak Detector. Model: El Tank Overfill I High-Level Sensor. Model; 0 Tank Overfill/High-Level Sensor. Model: E] Other(specify equipment type and model in Section E on Page 2). [1 Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 5-6 0 Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 DispenserID: 7-8 El Dispenser Containment Sensor(s). Model: r Containment Sensor(sy Model: ED Shear Valve(s). Ive(s). Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment El Dispenser Containment Sensor(s). Model: Sensor(s). Model 0 Shear Valve(s). El Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). El 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): 0 System set-up 0 Alarm history report Technician Name(print): DAVE WINKLER Signature: Certification No,: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. Testing Company Address: -416 2"'STREET GALT,CA 95632 - Date of Testing/Servicing: 8-17-2010 Monitoring System Certification Page 1 of 4 2/21/07