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W 0 REC Appendix VI MONITORING SYSTEM CERTIFICATION ;SLP 0 2017 For Use By Al Jurisdictions Within the State of Califomia Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations i;_ NMENTAL HEALTH rq I. i'_ This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be preps 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, . ART M E NT 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 Name: SAN JOAQUIN - GENERAL HOSPITAL Bldg. No.: Site Address: 500 W HOSPITAL RD Fadlity Contact Person: City: FRENCH CAMP Contact Phone No.: Zip: 95231 Mcke/Model of Monitoring System: DPW I —Touch Sentinel Date of Testing/Servicing: 08-21-17 B. Inventory of Equipment TestedlCertified Check the appropriate boxes to Indicate specific equipment fns ectedlserviced: Tank ID: DIESEL I@ In -Tank Gauging Probe. Model: MAG Tank ID: Signature: ❑ 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 I Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 30.3221-1 ❑Fill Sump Sensogs). 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 t Trench Senors). 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 Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ 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/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): ❑ 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) 7440113 Testing Company Address: 416 2" STREET GALT CA 95632 Date of Testing/Servicing: 08-21-17 Technician Name (print): Jesse Berumen Signature: g&,44�� Certification No.: 903703 License No: W4802 Testing Company Name: Bagley Enterprises Phone No. 209367-4800 Testing Company Address: 2270 Maggio #4 Lodi CA 95242 Date of TestinglServicing: 8-21-17 Monitoring System Certification Page 1 of 4 2/21/07