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4�ft E V E Appendix VI . bit ., MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California 5 2017 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Califomla Code of Regulations This form must be used tD document testing and servicing of monitoring equipment. A separate certfication or report must 4flr . p(sare d iiP,ln yi « d H y'�LT H each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the 181 =gym_ owner/operator. The owner/operator must submit* copy of this form to the local agency regulating UST systems within 30 days of test A. General Information FELIX RAMIREZ Signature: Facility Name: SAN JOAQUIN - GENERAL HOSPITAL Bldg, No.: License No: Site Address: 500 W HOSPITAL RD City: FRENCH CAMP Zip: 95231 Facility Contact Person: Contact Phone No.: ( ) M.^.4e/Model of Monitoring System: DPW I —Touch Sentinel Date of Testing/Servicing: 08-21-17 B. Inventory of Equipment Tested/Cerilfied Technician Nene (print): Jesse Beruman Check the appropriate boxes to Indicate specificequipment Ins ectedlserviced: g64�� Tank ID: DIESEL Tank ID: License No: ® in -Tank Gauging Probe. Model: MAO ❑ in -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 30.3221.2 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 30-3221-1 ❑ Piping Sump / Trench Senson(s). Model: ® Fig Sump Sensor(s). Model: 30-3221.1 ❑ FO Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leek 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). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ in -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump/ Trench Senors). Model: ❑ FIN Sump Senson(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leek Detector. Model: ❑ Mechanical Line Leek Detector. Model: ❑ 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 (spectfy equipment type and model in Section E on Page 2). DispenserlID: Dispenser ID: ❑ DIspenser Containment Senors). Model: ❑ Dispenser Containment Sensogs). Model: ❑ Shear Valves} ❑ Shear Valve(s} ❑ Dispenser Containment Flost(s) and Chaln(s). (3 Dispenser Containment Floats) 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/servicod in accordance with the manufacturers' guidelines. Attached to this CwtHkztlon 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 a# chef apply): ❑ System set-up ❑ Alarm history report Technician Name (print): FELIX RAMIREZ Signature: Certification No.: 6273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 STREET GALT, CA 96632 Date of Tes*WSwvicing: 08-21-17 Technician Nene (print): Jesse Beruman Signature: g64�� Certification No.: 903703 License No: 0�i� W4802 Testing Company Name: Bagley E nterpilses Phone No. 209.367-4800 Testing Company Address: 2270 Maggio #4 Lodi CA 95242 Date of TesdnglServicing: 8-21-17 _ Monitoring System Certification Page 1 of 4 2/21/07