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t � REQS Appendix VI JUI 1 .9 2017 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,Calif - of Regulations EEALTFi This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for PPIT d t_i each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system A „'L,vT owner/operator.The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30 da s of test date. A. General Information Facility Name: JESSE & KUL PETRO - ARCO Bldg.No.: Site Address: 1711 E. YOSEMITE AVE. City: MANTECA, CA Zip: 95336 Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/S rvicing: 6-21&630-17 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 Tank Size: 15 h Tank ID: 87-2 Tank Size: 15 K ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump/Trench Sensor(s). Model: 3 2 3 ® Piping Sump/Trench Sensor(s). Model: 323 ® Fill Sump Sensor(s). Model: 3 2 3 ® Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: P L L D ® Electronic Line Leak Detector. Model: SHARED LINE ❑ 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: Tank Size: Tank ID: 91 Tank Size: 12 K ❑ In-Tank Gauging Probe. Model: ® In-Tank Gauging Probe. Model: MAG 1 ❑ Annular Space or Vault Sensor. Model: ® Annular Space or Vault Sensor. Model: 409 ❑ Piping Sump/Trench Sensor(s). Model: ® 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: ® 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 ;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 ® Dispenser Containment Sensor(s). Model: 3 2 3 ® Dispenser Containment Sensors) 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: Dispenser ID: Model ❑Dispenser Containment ❑ Dispenser Containment Sensor(s). Sensor(s). Model: ❑ Shearvalve(s). ❑ShearValve(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 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): ®System set-up ®Alarm history report Technician Name(print): DAVE WINKLER Signature: (� Certification No.: B34975 License No: 04-166776) Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date of Testing/Servicing: 6-21&6-30.17 Monitoring System Certification Page 1 of 4 2/21/07