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s ^ • • Appendix VI MONITORING SYSTEM CERTIFICATION 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 forth must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for RECEIVE each monitoring system control panel by the technician who perforins 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 forth to the local agency regulating UST systems within 30 days of test date. MAR 14 2016 A. General Information Bldg.No.: ENVIRONMENTAL HEAT Facility Name: TOKAYSHELL Zip: 95240 PERMIT/SERVICES Site Address: 420 W.KETTLEMAN LN. City: LODI Contact Phone No.: (209)369.2790 Facility Contact Person: JAS Date of Testing/Servicing: 112012018 MakelModel of Monitoring System: VEEDER ROOT TLS 350 B. Inventory of Equipment Tested/Certified Check the a rcinate boxes to indicates cific a ui men t ins ectedlTank I d: Tank ID: 100 OCT Tank Tank Gauging ID: 87 Model: MAG 2 ® In-Tank Gauging Probe. Model: MAG 2 0 AnProbe. EL 0 Piping Sump/Trench Sensor(s). Model: 208 Annular Space or Vault Sensor. Model: SAME AS DIES ® Annular Space or Vault Sensor. Model: 409 0 Piping Sump/Trench Sensor(s). Model: 208 ® 0 Fill Sump Sensor(s). Model. ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 2000 0 L_1 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill(High-Level Sensor. Model: 0 Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). TO : 91 Tank ID: DIE nk Gauging Probe. Model: MAG 2 ® In-Tank Gauging Probe. Model: MAG 2 lar Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 409 0 Piping Sump/Trench Sensor(s). Model: 208 g p Sensor(s). Sensor(s). Model: 208 0 Fill Sump Sensor(s). Model: ump Sensor(s). Motlel: ® Mechanical Line Leak Detector. Model: 99 LD 2000 anical Line Leak Detector. Model: 99 LD 2000 0 Electronic Line Leak Detector. Model: ronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: [01 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 1 4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Floats)and Chain(s). Dispenser ID: 7 18 Dispenser ID: 5 18Model: 208 Model: 208 ® Dispenser Containment Sensor(s). ® Dispenser Containment Senmgs). 0 Shear Valve(s). ® Shear Valve(s). 0 Dispenser Containment Floats)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: WASTE OIL TANK Dispenser ID: 9 110 DIESEL ONLY ®Dispenser Containment Shears).( Model: 420-OVERFILLI 301 ANN. sor(s). ® Dispenser Containment SenModel: 208 Sensor(s). ® Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Floats)antl Chain(s). 'If the facility contains more tanks or dispensers,copy this form. Include immrnation for every tank antl dispenser at the fatality. C.Certification-I certify that the equipment identified in this document was inspected/serviced In accordance with the manufacturers' guitlelines.Attached to this Certification is information(e.g.manufacturers'checklists)necessary to verity that this information is correct antl a Plat Plan showing the layout of monttoring equiipme setup any equipment capable of larm history report erating such reports,I have also attached a copy of the report;(check all that apply): ®System Technician Name(print): ZANE NIMMO Signature: , �� License No: 04-1676 Certification pFFORDA-TEST Phone No. 209 744-0113 Testing Company y Name: Testing Company 418 2n°STREET GALT,CA 95632 Date of Testing/Servicing: 1/20/2016 Address: 2/21/07 Monitoring System Certification Pagel of 4