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Jun 02 20 , 03 : 06p 11 . 13 Appendix Vi MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Cal)fom(a Authority Cited : Chapter 6 .7 , Health and Safety Code ; Chapter 16 , Division 3, 'Title 23, California Code of Regulations Thisform must be used to decument testing and servill 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 owner/operator. The ownertoperator must submit a copy of this form to the local agency regutatirig UST systems wIlh:n 30 days of test date. A. GeneralInformaii Facility Name: WOODBRiDGE ARCO Bill No.: Site Address: 181106 LOWER SACRAMENTO RD City: WOODBRIDGE Ztp: 95258 Facility Contact Person: JASON Contact Phone Nn .: 209 3398238 MakeJModei of Monitoring System: VEEDER ROOT TLS 350 Date of TestinglServiring: 04-23-18 Be Inventory of Equipment Tested/Certified Check the aepro riate boxes to indicates ecific equipment ins ectedlserviced: Tank 87 lank lb: 91 0 In-Tank Gauging Probe, Model: MAG 7 10 in-Tank Gauging Probe. Model: MAG 7 0 Annular Space or Vault Sensor, Model: 409 IR Annular Space or Vault Sensor. Model: 409 0 Piping Sump I Trench Senscr(s), Model: 200 0 Piping Sump / Trench Sensor(s). Motel: 208 ❑ Fill Sump Sensor(s). Model : ❑ FBi Sump Sensor(s). Model: ® Mechanical Line Leak Detector, Model : 99 LD 2000 ® Mechanical Line Leak Detector. Model: FXIV ❑ Electronic Lina. Leak Detector, Model; ❑ Electronic Line Leak Detector, Model : ® Tank Overall f Nigh-Level Sensor. Model: FLAPPER ® Tank Overfill t Nigh-Levet Sensor, A'lodel; FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in S action E on Page 2), TanklD: DiESEL TanklD: ® In-Tank Gauging Probe. Madel: MAG 7 © in-Tank Gauging Probe , Model: ® Annular Space or Vault Sensor. Madel: el ❑ Annular Space or Vault Sensor. Mill ® Piping Sump / Trench Sensor(s). Model : 2D8 ❑ Piping Sump t Trench Sensor(s). Model: ❑ Flt Sump Sensor{s). Madel: ❑ Fill Sump Senscr(s}. Madel: 120 Mechanical Line teak Detector. Ni PE PETRO D ❑ Mechanical Una Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill ! HtghrLevel Sensor. Model. FLAPPER ❑ 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 S=Page Dis anseri6: 3-4DispenseciD : 7 -2 p(� Dispenser Containment Sensor(s}. Modei: 2118 11111 ® Dispenser Containment Senaor(s). Model:ShearVaive(s)_ R ShearValve(s). ❑ D)spenserCottainmentFloat(s) andChaii ❑ DspenserContalnmentFloal(s) andChain(s) Dispenser 1D: 5-6 Dispenser ID: 74 10 Dispenser Containment Sensot(s). Model; 2118 ® Dispenser Containment Sensor(s). Modei: 208 0 ShearVelve(s). ® ShearValve(s}. ❑ Dispenser Ctintainment Fioaf(s) and Chain(s). ❑ Dispenser Conte me Floats) and Chain(s). Dispenser ID: Dispenser l[Y ❑ Dispenser Containment ❑ Disperser ContainmentSensor(s), Model: _ Sensor(s} Model : ❑ ShearVaive{s) ❑ Shear Valve(s). ❑ Dispenser Containment Float{s) and Chains}. Q Dispenser Containment Floats) and Chain(s). I MEN '1f fhe facility contains more tanks or dispensers, copy this `oi Include information for every tank and dispenser at the facility. C. Certification - f certify that the equipment identified in this document was inspecledfservioed in accordance with the manufacturers' guidelines. Attached 10 this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Pian showing the Layout of monitoring equipment For any equipment capable of generating such reports, f have also attached a copy of the report; (check au thatap � System set-up 181 Alarm history report pfyj: Technician Name (print): FELIX RAMIRiZ Signature: }rr' Certification No.: 8883072-DT License li 08. 1740 all Company Name: AFFORDA TEST Phone No. (209} 744-0113 Testing Company Address: 4162r4 STREET GALT, CA 95632 Date of Tes5nglServicirg: 04-23-78 Monitoring system Certification Page t of 4