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Appendix VI r MONITORING SYSTEM CERTIFICATION RECEIVED ED 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 Co f I s This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be preps[ fQ[ r� ENTAL HEALTH each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank sy owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test cO MITSERVICES A. General Information JESSE & KUL PETRO - ARCO Bldg.No.: Facility Name: 95336 Site Address: 1711 E. YOSEMITE AVE. City: MANTECA, CA zip: Contact Phone No.: Facility Contact Person: ( ) Date of Testing/Servicing: 6/13/2016 Make/Model of Monitoring System: VEEDER ROOT TLS-350 B. Inventory of Fquipment Tested/Certified _Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tank Size: 15 K Tank ID: 87-2 Tank Size: 15 K ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 i29 Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 4 0 9 ® Piping Sump/Trench Sensor(s). Model: 3 2 3 ® Piping Sump/Trench Sensor(s). Model: 3 2 3 ® Fill Sump Sensor(s). Model: 3 2 3 E Fill Sump Sensor(s). Model: 2 0 8 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: P L L D E Electronic Line Leak Detector. Model: SHARED LINE ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: [I 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 Size: Tank ID: 91 Tank Size: 12 K Tank ID: Model: MAG 1 ElIn-TankGauging Probe. Model: ® In-Tank Gauging Probe. ❑ Annular Space or Vault Sensor. Model: E Annular Space or Vault Sensor. Model: 409 ❑ Piping Sump/Trench Sensor(s). Model: E Piping Sump/Trench Sensor(s). Model: 3 2 3 ❑ Fill Sump Sensor(s). Model: ® Fill Sump Sensor(s). Model: 3 2 3 ❑ Mechanical Line Leak Detector. Model: E 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 equipment type and model in Section E on Page 2). Dispenser ID: 1 / 2 Dispenser ID: 3 / 4 ® Dispenser Containment Sensor(s). Model: 3 2 3 ® Dispenser Containment Sensor(s), Model: 3 2 3 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5 / 6 Dispenser ID: 7 / 8 E Dispenser Containment Sensor(s). Model: 3 2 3 E Dispenser Containment Sensor(s). Model: 3 2 3 E Shear Valve(s). 2 Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). _Dispenser ID: Dispenser ID: E] Dispenser Containment Model Model: Sensor(s). F1Dispenser Containment Sensor(s). F� 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-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 verity that this information is correct o recta and a Plot Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have alsocopy of the report;(check all that apply): E System set-up E Alarm history report Technician Name(print): 7ANE NIMMO Signature: _ v License No: 04-1676 Certification No.: A28446 Phone No. 209 744-0113 Testing Company Name: AFFORDA-TEST 6/13/2016 Testing Company Address: 416 2ntl STREET GALT,CA 95632 Date of Testing/Servicing: 2/21/07 Monitoring System Certification Page 1 of 4