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E 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[, 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 Name: Site Address: ELDORADO FOOD MART Bldg. No.: 2320 N. EL DORADO ST. City: STOCKTON zip: 95204 Facility Contact Person: BOB, KATHY, & KELLY Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT SIMPLICITY Date of Testing/Servicing: 2/13/2018 B. Inventory of Equipment Tested/Certified Check the aoorooriate boxes to indicate specific eauioment inspected/serviced: Tank ID: 91 OCT Tank Size: 12 K Tank ID: 87 OCT ® In -Tank Gauging Probe. Tank Size: 12 K Model: M A G I ® In -Tank Gauging Probe. Model: M A G 7 ® Annular Space or Vault Sensor. Model: 3 0 2 ® Annular Space or Vault Sensor. Model: 3 0 3 ® Piping Sump / Trench Sensor(s). Model: 3 5 2 ® Piping Sump / Trench Sensor(s). Model: 3 5 2 ❑ 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 P L L D- 8 4 8 4 ® Electronic Line Leak Detector. Model: P L L D- 8 4 8 4 ❑ 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: DIESEL Tank Size: 12 K Tank ID: ❑ In -Tank Gauging Probe. Tank Size: Model: ® In -Tank Gauging Probe. Model M A G I ® Annular Space or Vault Sensor. Model: 3 0 2 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump /Trench Sensor(s). Model: 3 5 2 ❑ 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: ® Electronic Line Leak Detector. Model: P L L D - 8 4 8 4 ❑ 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: I / 2 Dispenser ID: 3 / 4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(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: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment 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 - 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): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0112 Testing Company Address: 416 2nd STREET GALT, CA 95632 Date of Testing/Servicing: 2/13/2018 Monitoring System Certification Page 1 of 4 2/21/07