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n 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 o 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 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 Bldg. No.: EL DORADO FOOD SHELL nano Site Addracc 2320 NORTH EL DORADO BLVD City: STOCKTON Zip: 95204 Facility Contact Parcnn Contact Phone No.: (209) 994-4400 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 2/11/2010 B. Inventory of Equipment Tested/Certified rti i, 66 � rnnrimto hnvoe to indicate snecific enuinmpnt insnerted/serviced: `If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - 1 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): S System set-up S 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. (209) 744-0113 Testing Company Address:14 6 2 STREET GALT, CA 95632 Date of Testing/Servicing: 02-11-10 Monitoring System Certification Page 1 of 4 2/21/07 Tank 1D: 87 Tank ID: 91 S In -Tank Gauging Probe, Model: MAG 1 S In -Tank Gauging Probe. Model: MAG 1 S Annular Space or Vault Sensor. Model: 302 S Annular Space or Vault Sensor. Model: 302 S Piping Sump / Trench Sensor(s), Model: 352 S 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: S Electronic Line Leak Detector. Model: PLLD S 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: ❑ In -Tank Gauging Probe. Model: 2%ln-Tank Gauging Probe. Model: MAG 1 S._ Annular Space or Vault Sensor. Model: 302 ❑ Annular Space or Vault Sensor. Model: E' Piping Sump / Trench Sensor(s). Model: 352 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: S Electronic Line Leak Detector. Model: PLLD ❑ Electronic Line Leak Detector. Model: Cl 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: S ShearValve(s). S Shear Valve(s). S Dispenser Containment Float(s) and Chain(s). S Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: S Shear Valve(s). S Shear Valve(s). S Dispenser Containment Float(s) and Chain(s). S Dispenser Containment Float(s) and Chain(s). Dispenser ID: DispenserlD: ❑ 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 contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - 1 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): S System set-up S 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. (209) 744-0113 Testing Company Address:14 6 2 STREET GALT, CA 95632 Date of Testing/Servicing: 02-11-10 Monitoring System Certification Page 1 of 4 2/21/07