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Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California ,r; Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, CaliF' ;� Regulations P' This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared 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 owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test d6g..JL 2 009 A. General Information SAN J0AQLnN rOUNTY Facility WATERLOO F& F Bldg. No.: ViN.FtC3?vthL= AL Site ALTH DEPARTMENT Site 3032 E WATERLOO RD City: STOCKTON CA Zip: Adtiracc• Facility Contact PP.fRnn' PAUL Contact Phone No.: (209) 466-5816 Make/Model of Monitoring System: INCON Date of Testing/Servicing: 6/23/2009 B. Inventory of Equipment Tested/Certified I di t ecific a ui ment Inanected/serviced• Check thea ro rlate boxes to n ca e s Tank ID: 87 OCT Tank ID: 91 OCT ® In -Tank Gauging Probe. ® Annular Space or Vault Sensor. Model: Model: MAG TBP -ELS ® in -Tank Gauging Probe. ® Annular Space or Vault Sensor. Model: MAG Model: TSP -ELS ® Piping Sump / Trench Sensor(s). Model: ULS ® Piping Sump / Trench Sensor(s). Model: ULS ❑ Fill Sump Sensor(s). ® Mechanical Line Leak Detector. Model: Model: RJ DLD ❑ Fill Sump Sensor(s). ® Mechanical Line Leak Detector. Model: Model: RJ DLD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DSL Tank ID: ® In -Tank Gauging Probe. Model: MAG ❑ in -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: SPLIT ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: ULS ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: RJ DLD ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ULS ❑Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model: ULS Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: ULS Sensor(s). Model: ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Shear Valve(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 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): David A. Winkler Signature: Certification No.: 34975 License No: OTT 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2 STREET GALT CA 95632 Date of Testing/Servicing: Monitoring System Certification Page 1 of 4 2/21/07