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Appendix VI 0 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 Code of 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 UST systems within 30 days of test date. A. General Information Facility RE N.- Site 341 AddrPcc Facility Contact PPrcnn• Make/Model of Mc SHELL T MAIN ST ANGLE System: VEEDER ROOT TLS350 Bldg. No.: city: RIPON Zip: Contact Phone No.: (209) 599-4454 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 1/24/2011 Tank ID: 87 Tank ID: Z In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 302 ❑ Annular Space or Vault Sensor. Model: Z Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: 1 ❑ Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector, Model: PLLD ❑ 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). Tank ID: Tank ID: 91 Z In -Tank Gauging Probe. Model: MAG I ❑ in -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model Z Annular Space or Vault Sensor. Model: 302 ❑ Piping Sump / Trench Sensor(s). Model: Z Piping Sump / Trench Sensor(s). Model: 208 ❑ 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: Z Electronic Line Leak Detector. Model: PLLD ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: El (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 Z Dispenser Containment Sensor(s). Model: 001 Z Dispenser Containment Sensor(s). Model: 001 Z Shear Valve(s). Z 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 Z Dispenser Containment Sensor(s). Model: 001 Z Dispenser Containment Sensor(s). Model: 001 Z Shear Valve(s). Z 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: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(:,). ❑ Dispenser Containment Float(s) and Chain(s). If the facility contains more tanKs! or dispensers, copy tins torm. Inciuce mtormation for every tal and aispenser at line faculty. 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 Piot 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): Z System set-up Z Alarm history report Technician Name (print): ZANE NIMMO Signature: Certification No.: 5263321Llf CA UTT2206 Nevada UST26756 Oregon License No: 04-1676 CA 2206 Nevada 26755 Oregon _ Testing Company Name: AF -ORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2' ` STREET GALT, CA 95632 Date of Testing/Servicing: 1-24-11 Monitoring System Certification Page 1 of 4 2/21/07