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Feb 05 16 05:36a Kevin Hur 209-8 1532 P. <br />Appendix V1 <br />MONITORING SYSTEM CERTIFICATION FEB 0 5 2016 <br />For Use By All jurisdictions Within the state of California <br />Authority CiWd:Chapter 61, Health and Safety COCIO; chapter 16, Division 3.nUe 23. Calflfoirrr oule <br />�r report <br />must <br />b! I)NMENTAL <br />to t tr <br />This form must be used to document testing and servicing of monitoring equipment A separate certification i rovided T� 11=11AIRTYFENT <br />'Offf <br />.. P <br />technician who performs " work. A copy of this form must be P S of <br />each monitoring system control panel by the to the local agency regulating UST systems within 30 day <br />Ownerloperstor. The owner! for must Submit a copy of this form <br />A. General information: Bldg. Na.: <br />Facility Name: GAS DEPOT Zip: 9� <br />Site Address: 1330 E YOSEMITE AVE City;: 6336 CA - <br />Facility contact Person: .. KEVIN Contact Phone Na.: own:0332 <br />Mak~ei of Monitoring System: VEF-DER ROOT TLS 350 <br />Date of Testing/Servicing: 1213012015 <br />B. Inventory of Equipment Tested/Certified ific Ins <br />serviced: <br />Check the approPdate boxes to Indicate sM !3uiE!ient <br />Tank Size: <br />Ta n =k5ll Z 0 =* <br />Tank ID: 87 Tank Size; <br />9 <br />Tank ID: 91 <br />Tank <br />Tan <br />lei. MAG 11 <br />g in -Tank Gauging Probe. Moi lel: m8al-- <br />G <br />k- <br />I 01.9 P' <br />0 in -Tank <br />7 <br />• in -Tank Gauging Probe- Model; MAG 1 <br />I_ SPLITL <br />®Annular Space or Vault Sensor. Model:- 409SP TW -DSL <br />Space -It e <br />0 Annular S P" " <br />• Annular Space or Vault Sensor. Model: 409 <br />;SPLI <br />T." (s) :1. <br />Piping Sump t Trench Sensor(s). Model: 352 <br />Sumpt SeZ, <br />0 Piping S. <br />R Piping Sump I Trench Sensor(s)- Model: 362 ------ <br />®Fill Sump Sensoqs). Model: 208 <br />0 Fill Sump Senso" <br />E] Fill Sump Sensor(s). Model: <br />Model: "LD 2000 <br />;ZD <br />Mechanical Line Leak Detector. Model: "Llo 2000 <br />.11, ne Le <br />0 Mechanical <br />* Mechanical Line Leak Detector. <br />ElectrOnic Une Leak Detector. Model: <br />0 Elac"nc Line Leal <br />* Electronic Line Leak Detector. model: <br />0 Tank overfill I High -Level Sensor. Model: <br />0 Tank 0 Mll I High <br />(3 Tank Overfill I High -Level Sensor. Model; <br />,2) <br />ED Other (specify equipment type and model in Section E on Page 2). <br />[3 other (spacify equipment type and model in Section E on Page 2). <br />0 Otha, (;� city equipment <br />Tank ID: DIE Tank Size: <br />Tank ID: Tank Size: <br />J@ in -Tank Gauging Probe. Model: MAG 1 <br />[3 IrTank Gauging Probe. Model: <br />a Annular Space or Vault Sensor. Model: 409 SPLIT WITH 91 <br />0 Annular Space or Vault Sensor. Model' <br />IM Piping Sump / Trench Sensor(s). Model: 352 <br />[3 piping Sump/ Trench Sensor(s). Model: <br />0 Fill Sump Sensor(s)- Model: 208­__� <br />[3 Fill Sump Sensor(s). Model: <br />0 mechanical Line Leak Detector. Model: SOLD 2000 <br />0 Mechanical Line Look Detector. Model: <br />0 SaWonic Line Leak Detector. Model: <br />[3 Electrronic Une Leak DeteotoL Model: <br />0 Tank overfill / High -Level Sensor. Model: <br />[3 Tank Overfill I High -Level Sensor. Model: <br />[3 Other (specify equipment type and model In Section E on Page 2). <br />0 Other (specify equipment type and model in Section I- on Page 2). <br />D <br />Dispenser ID: 1-2 <br />'Sp ,,, ns r I <br />Dispenser 10: 7-8 - <br />0 Dispenser containment Sensoqs). Model: 322 <br />se r <br />Dispenser <br />0 Dispenser ContainmentSOnsOr(s). Model: 322, <br />or Val"e <br />0 ShearValve(s). <br />0 SnearVatve(s). <br />[I Dispenser Containment Float(e) and Chain(s). <br />C] Dispenser Containment Floats) and Chain(s). <br />vmwgm- <br />D <br />Dispenser ID; 3-4 <br />EDIspenser <br />Dispenser ID: 9-10 <br />0 Dispenser Containment Sensor(s). Model: 208 <br />Dispenser Containment Sensor(s). Model: 322 <br />, as <br />V Ive <br />IN Sherr Valve(s). <br />0 Shear Valve(s). <br />[3 Dispenser C4rdainrrkent Float(s) and Chain(s). <br />0 t3 Dispenser Containment Float(s) and Chain(s). <br />Dispenser <br />ID: 5-6 <br />10 <br />DispenserID: 1142 <br />0 Dispenser Containment <br />N Dispenser Containment Sensor(s). Model: 322 <br />Sensor(s), Model: 322 <br />0 Shear Valve(s). <br />0 Shear Valve(s). <br />[3 Dispenser Containment Float(s) and Chain(s). <br />C] Dispenser Containment Floet(s) and Chain(s). <br />-very <br />*9 the facility contains more tanks or dispensers, copy this form. include Information for e tank and dispenser at the facility. <br />c. Certification - I certify that the equipment ideftfled in this document was inspectediserviced in accordance with the manufacturers' <br />guidelines. Attached to this Certification Is information (P -g. manufacturers' checklists) necessary to verify that this information Is Correct <br />and a Plot Plan showing the layout of monitoring _equipmerkt. For any equipment capable of genenating such reports, I have also aftched a <br />copy of the report; reheck all that apply). 0 System set-up [a Alarm history report <br />Technician Name (print): David Winkler Signature; Tc\� <br />Certification No.. 5263373 -UT License No: 081739 <br />Testing Company Name: AFFORDA-TEST Phone No. (2019) 7440112 <br />Testing Company Address: 416 2n0 STREEt GALT CA 95632 Date of Testing/Servicing: 12-30-15 <br />Monitoring system Certification <br />Pagel of 4 2121/07 <br />