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Y • i 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 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 Name: ELDORADO FOOD MART Bldg.No.: Site Address: 1901 S ELDORADO ST City: STOCKTON Zip: Facility Contact Person: VENUS Contact Phone No.: (209)495-4473 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 8/7/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins ected/serviced: Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: E In-Tank Gauging Probe. Model: MAG-1 E In-Tank Gauging Probe. Model: MAG-1 E Annular Space or Vault Sensor. Model: 420 E Annular Space or Vault Sensor. Model: 420 E Piping Sump/Trench Sensor(s). Model: 208 E Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: STP MLD E Mechanical Line Leak Detector. Model: STP MLD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/r-Ig^-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: Tank Size: Tank ID: Tank Size: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: t ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ 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: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Secton E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 3/4 E Dispenser Containment Serscr(s). Model: 208 E Dispenser Containment Sensor(s). Model: 208 E Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Ficat(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser!D: Dispenser 0: ❑ Dispenser Containment Sensor(s). Model: jj Dispenser Containment Sensor(s). Model: i ❑ Shear Vaive(s). it ❑ Shear Valve(s). ❑ Dispenser Containr„ent Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser 0: I 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). L-1 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.At'ached to this Certification is information(e.g.manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan snowing 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): Ed Stearns Signature: Certification No.: A31048 License No: Testing Company Narc AFFORDA-TEST Phone No. 209 744-0113 Testing Ccrnpany Adcress: 416 2n1 STREET GALT,CA 95632 Date of Testing/Servicing: 8/7/17 Monitoring Sys;sm Certification Page 1 of 4 2/21/07 FEB 2 0 2`343 �Ra�31�ra ENVIRONNiENIAL 1111"A ri1 FAoaa1��6 Di-,NrkR'FNIEN'r