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RECEIVED AUG 1 9 2020 Appendix VI MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL HEALTH 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 Cd`d8.6ftFYe Lt16QN, ' This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for 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: PACIFIC SERVICE STATION Bldg , No. : Site Address: 6131 PACIFIC AVE City: STOCKTON Zip: 95207 Facility Contact Person : DAV Contact Phone No. : (209) 9524862 Make/Model of Monitoring System : VEEDER ROOT TLS 350 Date of Testing/Servicing: 8/31 /2017 B . Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced : Tank ID : 87 Tank ID : 91 ® 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 : 352 ® Piping Sump / Trench Sensor(s). Model : 352 ❑ Fill Sump Sensor(s). Model : ❑ 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 : PLLD ® Tank Overfill / High- Level Sensor, Model : FLAPPER ® Tank Overfill / High-Level Sensor. Model : FLAPPER ❑ 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 : DIE Tank ID : ® In-Tank Gauging Probe , Model : MAG 1 ❑ In-Tank Gauging Probe. Model : ® Annular Space or Vault Sensor. Model : 302 ❑ Annular Space or Vault Sensor. Model : ® Piping Sump / Trench Sensor(s). Model : 352 ❑ Piping Sump / Trench Sensor(s). Model : ❑ Fill Sump Sensor(s). Model : ❑ 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 : ® Tank Overfill / High- Level Sensor. Model : FLAPPER ❑ 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 : 34 ❑ Dispenser Containment Sensor(s). Model : ❑ Dispenser Containment Sensor(s). Model : ® ShearValve(s) . ® ShearValve(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 : ❑ Dispenser Containment Sensor(s). Model : ® ShearValve(s), ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID : Dispenser ID : ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model : Sensor(s) . Model : ❑ ShearValve(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 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): FELIX RAMIREZ Signature: Certification No. : B34976 License No: 5273934-UT 08-1740 OTTL Testing Company Name: AFFORDA-TEST Phone No . (209) 744-0113 Testing Company Address : 4162 nd STREET GALT, CA 95632 Date of Testing/Servicing : 08-31 -17 Monitoring System Certification Page 1 of 4 2/21 /07