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tuoVE Appendix VI MONITORING SYSTEM CERTIFICATION MAR 11 2016 For Use By All Jurisdictions Wthin the State of California Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16, Division 3,Title 23,California Codeofe T ENTAL This form must be used to document testing and servicing of monitoring equipment.A separate certification or report mustre�orep.ereddion-PaRTY17-NT each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system 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: TOKAY SHELL Bldg.No.: Site Address: 420 W.KETTLEMAN LN. City: LODI Zip: 96240 Facility Contact Person: JAS Contact Phone No.: (209)369-2790 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 1120/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspects Ise"Iced: Tank ID: 87 Tank1D: 100 OCT N In-Tank Gauging Probe. Model: MAG 2 N In-Tank Gauging Probe. Model: MAG 2 N Annular Space or Vault Sensor. Model: 409 N Annular Space or Vault Sensor. Model: SAME AS DIESEL N Piping Sump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 99 LD 2000 N Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overall/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: DIE Tank ID: 91 E In-Tank Gauging Probe. Model: MAG 2 N In-Tank Gauging Probe. Model: MAG 2 N Annular Space or Vault Sensor. Model: 409 N Annular Space or Vault Sensor. Model: 409 N Piping Sump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 99 LD 2000 N Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Madel: ❑ 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 1 2 Dispenser ID: 3 / 4 E Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 E Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 6 1 6 Dispenser ID: 7 1 8 E Dispenser Containment Sensor(s). Model: 208 E Dispenser Containment Sensor(s). Model: 208 E Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chests). ❑ Dispenser Containment Float(s)and Chain(s). DispenserlD: 9 110 DIESEL ONLY DlspenserlD: WASTE OILTANK ®Dispenser Containment N Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 420-OVERFILLI 301 ANN. N Shear Velvets). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Cham(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 matthe 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): N System set-up E Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A29446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)7440113 Testing Company 416 2m STREET GALT,CA 95632 Date of Test ng/Servicing: 1/20/2016 Address: Monitoring System Certification Page 1 of 4 2/21/07