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F�It,;FED Appendix VI R E MONITORING SYSTEM CERTIFICATION OCT j 2 2018 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 prepEared RON M ENTAL HEALTH each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system DEPARTMENT 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. General Information Facility Bldg. No.: amo• CHARTER WAY SHELL F Site Address: 620 W CHARTER WAY City: STOCKTON CA Zip: Facility Contact pPrsce. SUKI Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT SYMPLICITY B. Inventory of Equipment Tested/Certified Date of Testing/Servicing: 11/20/2017 TanklD: 87 TanklD: 91 ® In -Tank Gauging Probe, Model: MAG 1 ® In -Tank Gauging Probe, Model: MAG 1 ® Annular Space or Vault Sensor. Model: 302 ® Annular Space or Vault Sensor. Model: 302 ® Piping Sump / Trench Sensor(s). Model: 352 ® Piping Sump/ Trench Sensor(s). Model: 352 [I Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector, Model: PLLD ® Electronic Line Leak Detector. Model: PLLD El Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: El Other (specify equipment type and model in Section E on Page 2). El Other (specify equipment type and model in Section E on Page 2). Tank ID: DSL TanklD: ® In -Tank Gauging Probe, Model: MAG 1 ElIn-TankGauging Probe. Model: ® Annular Space or Vault Sensor, Model: 302 E] Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 352 El Piping Sump/ Trench Sensor(s). Model: [I Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: [I Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector, Model: PLLD E] Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: El Tank Overfill / High -Level Sensor. Model: [I Other (specify equipment type and model in Section E on Page 2). El Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 5-6 ❑ Dispenser Containment Sensor(s). Model: [3 Dispenser Containment Sensor(s). Model: ® ShearValve(s). ® ShearValve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 [I Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® ShearValve(s), ® ShearValve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 El Dispenser Containment El Dispenser Containment Sensor(s). Model: Sensor(s). Model: ® ShearValve(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): Certification No.: 526331 License No: 08-1739 Testing Company Name: Testing Company Address: DAVE WINKLER 4162 nd STREET GALT, CA 95632 Signature: (�_� Phone No. (209) 744-0113 Date of Testing/Servicing: 11-20-17 Monitoring System Certification Page 1 of 4 2/21/07 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): Certification No.: 526331 License No: 08-1739 Testing Company Name: Testing Company Address: DAVE WINKLER 4162 nd STREET GALT, CA 95632 Signature: (�_� Phone No. (209) 744-0113 Date of Testing/Servicing: 11-20-17 Monitoring System Certification Page 1 of 4 2/21/07