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Appendix VI RECEIVED 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,California Cod ffpUNA r,,7,t6 H Regulations 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 LIST systems within 30 days of test date. A. General Information Facility M.— COUNTRY CLUB 76 Bldg.No.: Site Arldrp.qq- 2575 COUNTRY CLUB City: STOCKTON CA Zip: Facility Contact Pp.r.qnn, Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT TILS 350 Date of Testing/Servicing: 1/26/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tank ID: 91 0 In-Tank Gauging Probe. Model: MAG 1 1@ In-Tank Gauging Probe. Model: MAG I ED Annular Space or Vault Sensor. Model: 420 0 Annular Space or Vault Sensor. Model: 420 • Piping Sump/Trench Sensor(s). Model: 208and 304 brine 0 Piping Sump/Trench Sensor(s). Model: 208and 304 brine • Fill Sump Sensor(s). Model: 208and 304 brine 0 Fill Sump Sensor(s). Model: 208 and 304 brine 0 Mechanical Line Leak Detector. Model: LD-2000 0 Mechanical Line Leak Detector. Model: RED JACKET El Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: 1771 Tank Overfill/High-Level Sensor. Model: El 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 ID: DSL Tank ID: JZ In-Tank Gauging Probe. Model: MAG1 El In-Tank Gauging Probe. Model: El Annular Space or Vault Sensor. Model: SPLIT W 91 E] Annular Space or Vault Sensor. Model: lZ Piping Sump/Trench Sensor(s). Model: 208 [1 Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 208 [1 Fill Sump Sensor(s). Model: ED Mechanical Line Leak Detector. Model: RED JACKET El Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: E] Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). [1 Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 7-8 0 Dispenser Containment Sensor(s). Model: 208 ALSO 304 BRINE Z Dispenser Containment Sensor(s). Model: 20 ALSO 304 BRINE 8 0 Shear Valve(s). 0 Shear Valve(s). E] Dispenser Containment Float(s)and Chain(s). [3 Dispenser Containment Float(s)and Chain(s), Dispenser ID: 3-4 Dispenser ID: 9-10 ED Dispenser Containment Sensor(s). Model: 208 ALSO 304 BRINE El Dispenser Containment Sensor(s), Model: 208 ALSO 304 BRINE [0 Shear Valve(s). 0 Shear Valve(s). [] Dispenser Containment Float(s)and Chain(s). [I Dispenser Containment Float(s)and Chain(s). Dispenser ID: 6-6 Dispenser ID: VENT SUMP 0 Dispenser Containment [D Dispenser Containment Sensor(s). Model: 208 ALSO 304 BRINE Sensor(s). Model: 208 ALSO 304 BRINE ED ShearValve(s). El Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). El 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): [I System set-up El Alarm history report Technician Name(print): DAVE WINKLER Signature: Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2nd STREET GALT,CA 95632_ Date of Testing/Servicing: 1-26-2011 Monitoring System Certification Page I of 4 2/21/07 C, 6(oftkV'