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0 Appendix VI 10 RECEIVE.11 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California This form must be used to document testing and servicing of monitoring equipment A separate certification or report must each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to thM=NMENTAL ownerloperator. The owner/operator must submit a copy of this form to the local agency regulating LIST system within 30 dayelelV41li 1Wpr=1)h0'n=IkIT A. General Information Facility Name: SAN JOAQUIN HOSPITAL Bldg. No.: Site Address: 60 W HOSPITAL RD City: FRENCH CAMP Zip: Facility Contact Person: Jesse Escotto Contact Phone No.: ( Make/Model of Monitoring System: OPW Date of Testing/Servicing: 08-17-15 B. inventory of Equipment Tested/Certified Check the aepMeriate boxes to indicate specific equiprnent inspected/serviced: Tank ID: DESEL Tank 10: • In -Tank Gauging Probe. Model: MAG [] in -Tank Gauging Probe. Model: • Annular Space or Vault Sensor. Model: 30-221-2 0 Annular Space or Vault Sensor. Model: • Piping Sump / Trench Sensor(s). Model: 30-2214 [1 Piping Sump / Trench Sensor(s). Model: • Fill Sump Sensor(s). Mode[. 30-2214 n Fill Sump Sensor(s). Model: [] Mechanical Line Leak Detector. Model: 171 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: 0 Tank Overfill / High -Level Sensor. Model: [] Dew (specify equipment type and model in Section E on Page 2). Q Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: 0 In -Tank Gauging Probe. Model: 0 in -Tank Gauging Probe. Model: ❑ Annular Spare or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: 0 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: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: 0 Tank Overfill I High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). 0 Other (specify equipment type and model in Section E on Page 2). Dispenser ID: DlWnserlD: [I Dispenser Containment Sensoqs). Model: F_] Dispenser Containment Sensor(s). Model: [3 Shear Valve(s). 0 Shear Valve(s). n Dispenser Containment FkWs) and Chain(s). [3 Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: [I Dispenser Containment 0 Dispenser Containment Sensor(s). Model: Sensor(s). Model: [3 Shear Valve(s). [3 Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). E] 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 -1 cerft Mat the equipment Identified In this document was Inspectullserviced In accordance with the manufacturers' guidelines. Attached to this Certification Is Information (e.g. manufacturers' checklists) necessary to verify Met this Information 15 correct and a Plot Plan showing the layout of monitoring equipmeft For any equipment capable of generating such reports, I have also attached a copy of the report; (dwA all that apply): [3 System set-up [3 Alarm history report Technician Name (print): FELIX RAMIREZ Signature: Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 74�4-0113 Testing Company Address:- 416 2m STREET GALT CA 2 Date of Testing/Servicing: 08-17-15 Technician Name (print): (,jM g Signature: Certification No.:0 1 -,410 zv If License N Testing Company Name: Phone No. 7- o Testing Company Address: Date of TestingfServicing: 08-17-15 Monitoring System Certification Page 1 of 4 2/21/07