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0 F-D Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited. Chapter 6-7, Health and Safety Code; Chapter 16, Division 3, Title 23, Galiforni vile rpt Rag�+latI its "_ I -I This loan must be used to document testing and servicing of monitoring equipment A separate certification o: report must be prepare¢ rot 1-C each monitoring System control panel by the technician who performs the work. A oopy of this form must be pros-ded to the tank systEm owneuoperalor The ownerfoperator must submit a Cnpy of this form to the local agency regulating UST systems Whin 30 days of test cage A General Information FaciW Name (INITED PACIFICH 5446 SiteAtldress t403COUNTRY CLUB BLVD Facility C,on+act Pefson:. MakelMcdel of hionAoring system bldg No.. City: 5TOCKT(7N Zip. 9-5204 . _. Cpntact Pliooc No : ; �__._... V1'_'1_I)ER1 X)TTLS34(1 Date of Testing4ervicGng: 5tJJ2017 B Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate speeiFic a ui ment inspectedfservice& Tank ID: 87 Tank Size: Tank ID: 91 Tank Size - 0 In -Tank Gauging Probe. Model: MAG -I ® in -Tank Gaug ng Probe. MOCei h'IAC-1 ® Annular Space or Vault Sensor Model 302 G Annular Space or Vault Sensor. Model 302 0 Piping Sump i Trench Sensor{s) Model 209 ® Piping Sump ! Trench Sensor(s) Model 2163 ❑ Fal Sump Sensors) h"Wel ❑ Fill Sump Sensor(s). ►•9ode1' 0 Mechaneal Line LeaK Deteacr. htodel LD2000 ® Mechanica Line Leak Detector. Model: I.D2000 ❑ F_Mutronic. (,ure Leak Detector Model ❑ Electronic Lino Leak Detector Model. 8 Tank Overfill? High -Level Sensrz. hlaiel: FLArPER Tank Overfcil l Hign•Levef Sensor. Model; FLAPPED ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E nn Page 2) Tank ID: DIE Tank Size: Tank ID: _ Tank Seize; ® In.Tank Gauging Probe. Model. %1A(1-1 0 in -Tank Uauging Probe Mocel ❑ Annular Space of Vault Sensor Model. 363 ❑ Annular Space or Vaul! Sensor. Model 0 Piping Sump Trench Sensor(s) mcdet, VIh` ❑ Piping Sump f Trench Sensor(s). Model El FG:I Sump Sensor(s) Modell: ❑ Fill Sump Sensor(s). Model (D Mechanical Line Leak Detector Model I'D2000 ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line teak Detector Abdel ❑ Electronic Line Leak Detector. hfodel- ® Tank Overfill t tf,gh-Levet Sensor Model. FI-APPER ❑ Tank Overfill i High-Lovel Sensor. ?.Wel 0 OIC.er (specify equipment type and model in Section E on Page 2). ❑ Otherce ` s e (p .y q ui prnent type and model rn Section E on Page ?) Dispenser ID: I -_' Dispenser ID: 3-1 _ ❑ Dispenser Containment SCnsor(s). Model ❑ D Spenser Containment Senscu(s), Model. 0 Shear Valve(s). ® Shear Valves) Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Floats) and Chain(s). Dispenser iD: :-b Dispenser ID: 7-8 ❑ Disper*er Conla-nmerrl Sensors) Mode4 adel.© 0 Dispenser Containment Sensor(s). -Model- 121ShearValve(s) 0 ShearValve(s) Ikswriser Cpntainment Ftoal{s) and Chain(s). ® Dispenser Containment Float(s) and Chain{s) Dispenser ID. Dispenser lD: Dispenser Containment ❑ Dispenser Contairunent Sensor(s) Model: _ Sensor(s). Model: 0 Shear Valve(&) ❑ Shear Vatve(s) ❑ Dispenser Ccntainment rtoal(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s). 'If the fariliy Contains mere tanks or dispensers. Copy this form include informaton fpr every lank and dispenser at the facility C- Certification - I certify that the equipment Identified In this document was Insp�ctedlserviced In accordance with the manufacturers' guidelines. Attached to thls Certification is information (e.g. manufacturers' €hecklists) necessary to verify that this Information is Corset 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 o8 rhar apply): system set-up M Alarm history report teMntoan Name (print): Ed Stearns Signature: J _ Certification No.: A31048. Uccnsc No. Testing Company Name: AFF4RQA-TEST Phone Na Y.. _ *a (209) 744-0113 w Testing CbrnpanyAddress 4152 STREET GALT, CA 95632 Date of TestingrServ,png i?( 7 Monitoring System Certification Pagel 0 4 212 1?D7