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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, California Code of Regulations 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 Ownerloperator. The ownertoperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. Generallnformatiow Facility Name: CRM -Pacific Chevron Bldg. No.: Site Address, 6633 PACIFIC AVE City: STOCKTON CA Zip: 95207 Facility Contact Person: Contact Phone No.: ( } Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 5126/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspectediserviced: Tank ID: 87 1 Tank Size: Tank ID: 872 Tank Size: ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump 1 Trench Sensor(s). Model: 352 ® Piping Sump 1 Trench Sensor(s). Model: 352 ® Fill Sump Sensor(s). Model. 208 ® Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill ! High -Level Sensor. Model: ❑ Tank Overfill I High -Level Sensor. Model: ❑ 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: 91 Tank Size: Tank ID: Tank Size: ❑ In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model- MAG 1 ® Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump 1 Trench Sensor(s). Model: 352 ❑ Piping Sump 1 Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill J High -Level Sensor. Model ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispense ID: 1-2 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s)- ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 9-10 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 6-6 Dispenser ID: 11-12 ® Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s)- Model- 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(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 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 that apply): ❑ system set-up ❑ Alarm history report Technician Name (print): David Winkler Signature: \ i �1 Certification No-- 5263373 -UT License No: V08-1739 Testing Company Name: AFFORDA-TEST Phone No. (2 9) 744-0112 T Testing Company Address: 416 2"d STREET GALT CA 95632 T Date of Testing/Servicing: 5-26-17 Monitoring System Certification Page 1 of 4 2121107