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Appendix VI _ ■ :�f5Eu1.1 7::.; .. ��r:il MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within&e State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23, California Co Regulations Iripf 0 S 2010 This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be preparAAW JOA:11"i_;!J COUNTY each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system ✓IITARO'NWENTAL owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of tesq-W LTH DEPARTMENT A. General Information Facility N,,,,o. SKY MART VALERO Bldg.No.: _ Site Artdraca• 713 N ELDORADO ST City: STOCKTON CA Zip: Facility Contact Pr rcnn• ALI Contact Phone No.: (209)939-1755 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 4/28/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/servi ed: _ Tank ID: 87 oct Tank ID 91 oct ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 302 ® Annular Space or Vault Sensor. Model: 302 ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model. ® Electronic Line Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model. PLLD ❑ 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: DSL Tank ID NA ® In-Tank Gauging Probe. Model: MAG 1 [I In-Tank Gauging Probe. Model. W ® Annular Space or Vault Sensor. Model: SPLIT 91 E] Annu r Space or Vault Sensor. Model. ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ❑ Electronic Line Leak Detector. Model: i ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor, Mo el: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model I i Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Mo(el: 208 ® Shear Valve(s). ® Shea Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispen erID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shea Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9-10 Dispen er ID: 11-12 ® Disp nser Containment ® Dispenser Containment Sensor(s). Model 208 Sen or(s). Model: 208 ® Shear Valve(s). ® She r Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Disp nser 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 f generating such reports,I have also attached a copy of the report;(check all that applv): ®System set-up ®Alarm history report Technician Name(print): DAVE WINKLER Signature: �,,_V__) Certification No.: 5263373-UT License N : 08-1739 Testing Company Name: AFFORDA-TEST Phone No _ 209)744-0113 Testing Company Address: 416 2 STREET GALT,CA 95632 Date of Te sting/Servicing: 4-28-2010 Monitoring System Certification Page 1 of 4 2/21/07