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Appendix VI 04/ 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 MAR 2 1 2011 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 {oTY 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 TEiEiT Facility N.— EL DORADO FOOD SHELL Bldg. No.: Site ArldrPSG, 2320 NORTH EL DORADO BLVD City: STOCKTON Zip: 95204 Facility Contact Parenn- Contact Phone No.: (209) 994-4400 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 2/8/2011 B. Inventory of Equipment Tested/Certified ChPrk thw L.. --- r..:...r__._ -- ---__ __ -.._-____ —,r ......... .. ...r...,:..... w GY IQY ,vf .vu. Tank ID: 87 Tank ID: 91 E in -Tank Gauging Probe, Model: MAG 1 E In -Tank Gauging Probe, Model: MAG 1 E Annular Space or Vault Sensor. Model: 302 E Annular Space or Vault Sensor. Model: 302 E Piping Sump / Trench Sensor(s). Model: 352 E Piping Sump/ Trench Sensor(s). Model: 352 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD E Electronic Line Leak Detector. Model: PLLD ❑ Tank Overfill / 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), Tank ID: DIE Tank ID: E In -Tank Gauging Probe. Model: MAG 1 ❑ in -Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: 302 ❑ Annular Space or Vault Sensor. Model: 4 Piping Sump / Trench Sensor(s). Model: 352 ❑ Piping Sump / Trench Sensor(s). Model: ❑ rill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: E, Electronic Line Leak Detector. Model: PLLD ❑ 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). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: E ShearValve(s). ® Shear Valve(s). E Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 l ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). E Dispenser Containment Float(s) and Chain(s). E Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). 'If the facility cnntains mora f L4 .,r ai. : r 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): E System set-up E Alarm history report Technician Name (print): FELIX RAMIREZ Signature: Certification No.: B34976 License No: 5273934 -UT 08-1740 OTTL Testing Company Name: AFFORDA-TEST Phone No. _L 09) 744-0113 Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 02-08-11 -- Monitoring System Certification Page 1 of 4 2/21/07