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40 Appendix VI 40 RECEIVED MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California ((�� °° TT Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regul�tfdn 2014 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared f each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system I BT 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. DEPARTMENT A. General Information Facility Name: SAN JOAQUIN HOSPITAL Bldg. No.: Site Address: 500 W HOSPITAL RD City: FRENCH CAMP Zip: Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: OPW Date of Testing/Servicing: 08-22-14 B. Inventory of Equipment Tested/Certified Check the aepro nate boxes to indicatespecific a ui ment ins ected/serviced: Tank ID: RED DIESEL Tank ID: ® in -Tank Gauging Probe. Model: MAG ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 30-221-2 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump /Trench Sensor(s). Model: 30-221-1 ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 30-221-1 ❑ 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: ❑ 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 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: ❑ 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). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Vaive(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ 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 Vaive(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ 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): ❑ System set-up ❑ 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) 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 08-22-14 Monitoring System Certification Page 1 of 4 2/21/07