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• Appendix VI 0 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California E///110 , Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16, Division 3,Title 23,California Code of This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for/SERV/ES rH 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: 95240 Facility Contact Person: JAS Contact Phone No.: (209)369-2790 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 1-17.2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tari 100 OCT 0 In-Tank Gauging Probe. Model: MAG 2 ® In-Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: SAME AS DIESEL ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 [I 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 ❑ 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). ❑ Others equipment ( peci ty type and model in Section E on Page 2). Tank ID: DIE Tank ID: 91 ® In-Tank Gauging Probe. Model: MAG 2 ® In-Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 0 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 Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify ty equipment type and model in Section E on Page 2). DispenserlD: 1 / 2 Dispenser ID: 3 / 4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 206 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5 1 6 Dispenser ID: 7 / 8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9 / 10 DIESEL ONLY Dispenser ID: WASTE OIL TANK ®Dispenser Containment ® Dispenser Containment Senwhs), Model: 208 Sensor(s). Model: 420-OVERFILLI 301 ANN. ® Shear Valve(s). ❑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-1 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 a//that app/y): ®System set-up ®Alarm history report Technician Name(print): DAVE WINKLER Signature: (� 1 Certification No.: 334875 License No: 041676 —� Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 410 2" STREET GALT CA 95632 Date of Testing/Servicing: 1-17-17 Monitoring System Certification Page 1 of 4 2/21/07