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• RF Appendix Vl Ufvi 2 2017 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Catiforoia p, Authority Cited: Chapter 16.7, Health and Safety Code; Chapter 16, Division 3, TWO 23, ca,ifornials~lti ot> ►ilsa��+r r�? 9 HEALTH This torn must be used to document lost 49 and searcing of monitoring equipment. A separate Cerlifcalion or report must oe paepzred fof_w.,_� each monitoring system control panel by the technician who performs the urork A copy of this form must be provided to the tanks} stem i !f O%m lo¢erator. The c wnerloperalor mull submit a copy of this form to the local agerty regulating LIST systems x thin 30 days of test rate. A Generallnfomabon- Faeifily Name. UNITED PAC 5446 JIFFY LUBE _ Bldg. No SleAgidress 1403COUNTRYCLUB BLVD City. STOCKTON CA Zip: 95704 Facility Contact Person. Contact Phone No ( ) MakOModel of Monitoring System RONAN Date of TestingrServiring' 5x191'2017 B. Inventory of Equipment TestedlGertified Check the arinrnnrimn tanYae to inrrirara mrsnrifiw....•..aa......:.....a- ,. — ,c,e Y .y s.' ria vI vIa}ti1rxIa, wFy info Ivat.I. JJr%dvVU II I I VI II IriiIVl 1 IVI VVL'Fy ttlnM1 dl iii UfyjJCnWf dl Lill: fi1U I l Ly C. Certificalion • I certify that the equipment identified In this document was inspectefterviced In accordance with the manufacturers' guidelines_ Attached to this Cortificationis information (e.g, manufacturers' checklists) necessary to verify that this information Is Correct and a Plot Plan Showing the layout of monitarinequipment. For any equipment capable of generating such roports, I have also attached a COPY of the MpOrl; {clerk nit rhm nppJr): � System setup El Alarm history report Technician Name (print): Dav d vvinkler Stgnature' Certification No. 5263373 t1T _ (- wise No 08-1733 Testing Company Name AFFOROA•TEST Phone No. (2t 74-0.0112 festing Company Address 416 2STRELT GALT, CA 55632 Date of TeslrnglServicing_ 5-19-17 Monitoring System Certification Parte i of 4 7x2 t +07, Tank Size; Tank ID: Tank.Size-. FD: Probe, Model. ❑ In•TankGaugingProbe. Morel. r Vault Sensor Modet: LS 18 ❑ Annular Space or Vault Sensor f,rodel. rench Sensor{s} Model ❑ Piping Sumo I Trench Sensor(s) ttpdel. El Fin Sump Senso(s) Model LS3 ❑ FFII Sump Sensors) Model: Q Mechanital Line Leak Oe;ee:or Model ❑ Mechanical Line Leak Detector Mow, ❑ Eledromsc 1Lne Leak Detector. Model ❑ Electronic Line Leak Detector. Model: ❑x Tank Overfill 1 High -Level Sensor. Model L$3 ❑ Other (specify equipment type and model in Section I on Page 2). ❑ Tank Owerfi I x High,Levet Sensor. Model. ❑ Other (specify equipment type and model In SCGion E on Page 2) Tank 10• Tank Size.- ize:In-tank Tank 1D: DIF_ Tank Size: In-rankGauging Prue Mode]: C1 In -Tank Gauging Prone Model. ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor. Model ❑ Piping Sump; Trench Sensor(s)- Model: ❑ Piping Sump 1 Trench Sansor(s). Model ❑ Fall Sump Sensor(s) Model Cl Fill Sump Sonsw(s) Model Mechanical Line Leak Detector Model. ❑ Mechanical Line Leak Detector Modcl ❑ Electronic Line Leah Deleclor Model; ❑ Electronic Lne Leat Deieetor. Model ❑ Tank Overfta I High -Level Sensor MOW! ❑ Tank Overfill r Nigh -Level Sensor. Model- ❑ Other (specify equipment type and moiler in Section E on Page 2). ( other (specfy equipment type ana model in Section E on Page 2). DispenserlD: Dispenser ID: EJ Drspenscr Containment Sensors) Model © Dispenser Containment Sensor(s) Mopes ❑ Shear Valve(s) ❑ Shear Valve(s)- 0Dispenser Containment Ftoat(s) antl Chain(s) ❑ Dispenser Ccntainrr.,em Float(s) and Dispenser 10: Chain(s). Dispenser ID: C) OiWnscr Containment Sensor(s). Model ❑ Dispenser Containment Sensors) Model: ❑ Snear Valve(si ❑ Shear Valve(s) ❑ Dispenser Containment Float(S) and Chain(s). ❑ Dispenser Containment Floats) and Chain($), Dispenser ID: Dispenser 10: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s) Model: Sensor(s). Model, ❑ Shear Valve(s). ❑ Shear Valvie(s). ❑ Di*,per*er Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chaln(s). ,. — ,c,e Y .y s.' ria vI vIa}ti1rxIa, wFy info Ivat.I. JJr%dvVU II I I VI II IriiIVl 1 IVI VVL'Fy ttlnM1 dl iii UfyjJCnWf dl Lill: fi1U I l Ly C. Certificalion • I certify that the equipment identified In this document was inspectefterviced In accordance with the manufacturers' guidelines_ Attached to this Cortificationis information (e.g, manufacturers' checklists) necessary to verify that this information Is Correct and a Plot Plan Showing the layout of monitarinequipment. For any equipment capable of generating such roports, I have also attached a COPY of the MpOrl; {clerk nit rhm nppJr): � System setup El Alarm history report Technician Name (print): Dav d vvinkler Stgnature' Certification No. 5263373 t1T _ (- wise No 08-1733 Testing Company Name AFFOROA•TEST Phone No. (2t 74-0.0112 festing Company Address 416 2STRELT GALT, CA 55632 Date of TeslrnglServicing_ 5-19-17 Monitoring System Certification Parte i of 4 7x2 t +07,