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0 RECEIVED Appendix VI JANz 8 z 016 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California JE Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code o This form must be used to document testing and Servicing of monitoring equipment. A separate certification or report must be fMER L H r) each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank Sys r4f� i/�CE 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: GAS DEPOT Bldg. No.: Site Address: 1330 E YOSEMITE AVE City: MANTECA CA Zip: 95336 Facility Contact Person: KEVIN Contact Phone No.: (209) 825-0332 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 1213012015 B. Inventory of Equipment Tested/Certified equipment insl cted/serviced: Check thea ro riate boxes to indicates glfic Size: Tank ID: 91 Tank Size: Model: MAG 1 FTankID:Tank ging Probe. Model: MAG 7 In -Tank Gauging Probe. ® Annular Space or Vault Sensor. Model: 409 SPLIT W DSL ce or Vault Sensor. Model: 409 ® Piping Sump / Trench Sensor(s). Model: 352 / Trench Sensor(s). Model: 352 ®Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99LD 2000 ® Mechanical Line Leak Detector. Model: 99LD 2000 ❑Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: ❑ E ❑Tank Overfill / High -Level Sensor. Model: [3 Tank Overfill / High -Level Sensor. Model: [I 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: DIE Tank Size: Tank ID: Tank Size: ® -In-Tank Gauging Probe. Model: MAG 1 ElIn-TankGauging Probe. Model: Model: Annular Space or Vault Sensor. Model: 409 SPLIT WITH 91 ❑ Annular Space or Vault Sensor. Model:Model: ® Piping Sump /Trench Sensor(s). Model: 352 ❑ Piping Sump / Trench Sensor(s). ® Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. Model: ® Mechanical Line Leak Detector. Model: 99LD 2000 El 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). [I Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 7-8 Dispenser ID: 1-2 ® Dispenser Containment Sensor(s). Model: 322 Di Dispenser Containment Sensor(s). Model: 322 ®Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9-10 Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 322 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). DispenserlD: 11-12 Dispenser ID: 5-6 ® Dispenser Containment ser Containment Sensor(s). Model: 322 Sensor(s). Model: 322 ® ShearVaive(s). valve(s). ❑Dispenser Containment Float(s) and Chain(s). Containment Float(s) and Chain(s). include information for every tank and dispenser at the facility. "If the facility contains more tanks or dispensers, copy this form. 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 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 all char apply): ® System set-up ®Alarm history report Technician Name (print): David Winkler Signature: Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. 209 744-0112 Testing Company Address: 416 2nd STREET GALT, CA 95632 Date of Testing/Servicing: 12-30-15 2/21/07 Monitoring System Certification Page 1 of 4