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Appendix vi SEP 2016 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 Cade of Regulations This form must be used to document testing and servicing of monitoring equipment. nt. A separate certification or report must be prepared for each monitoring system control pared by the technician who performs the work. A copy of this form must be provided to the tank system ownerloperator. The owrer/operstor must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. A. General Information Fadlity Name: Site Address: Facility Contact Person: SAN JOAQUIN CO. - GENERAL HOSPITAL Bldg. No.: 500 HOSPITAL RD City. FRENCH CAMP Contact Phone No.: ( ) Zip: 95231 Make/Model of Monitoring System: OP W -SITE SENTINEL ffOUCH Date of Testing/Servicing: 8/252016 a. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment Inspectediserviced: Tank ID: RED DIE Tank Size: Tank ID: Tank Size: I@ In -Tank Gauging Prue. Model: MAG ❑ In -Tank Gauging Probe. Model: ® Annular Spans or Vault Sensor. Model: 30-3221-2 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump I Trench Sensor(s). Model: 30-3221-1 ❑ Piping Sump I Trench Sensor(s� Model: ® Fig Sump Sensogs). Model: 3 0 - 3 2 2 1 -1 ❑ Fill Sump Sensor(s), Model: ❑ Mechanical Lire Leek Detector. Mord: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Una Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model In Seton E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank BD: Tank Size: ank ID: Tank Size: [IIn Tank Gauging Probe. Model: In -Tank Gauging Probe. rE3 Model: [I Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: ❑ Piping Sump f Trench Sensor(s). Model: ❑ 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 Lire 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� ❑ Otter (specify equipment type and model In Section E of Page 2). Dispensw ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dtspensor Containment Senors). Model: ❑ Shear Valve(s} ❑ Shear Vaive(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Disperser Containment Floags) and Chaln(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: I ❑ Shear Valve(s). ❑ Shear Valve(s� ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Flows) and Chatln(s). 'f the facility contains more tanks or dispmnsers, copy this form. Include information for every tank and dispenser at the fatality. C. Certification - I certify that the equipment identified in this document was Inspected/serviced in accordance with the manufachtrers' guidelines. Attached to this Certification is IMormation (e.g. manufacturers' checklists) necessary to verify that this infarmatbn 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 rharapp(y): ® System aetarp ® Alarm history report Technician Name (print): ZANE NIMMO Signature: Certification No.: A25446 License No: 041676 Testing Company Name: AFFORDA-TEST Phone No. j209) 744-0112 Testing Company Address: 418 STREET GALT, CA 95632 Date of TestinglServlcing: 8-23-16 Technician Name (print): - .) Signature: Certification No.:�� License No69--mg, "I Testing Company Name: _ $0 V'94�— Phone No. Testing Company Address — 0_ Date of Testing/Servicing.' 8-23-16 Monitoring System Certification Ot t- 640\' ��Jr 42 Page 1 of 4 2/21/07