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Parkwood Gas& Food 2 98888157 p.15 121Z�,j 11[7_'� Appendix V1 JUL MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California E N V F,C��Q'7�r77'-N1 Tr'\L Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16,Division 3,Title 23,California C "9qTiv3ENT This form must be used to document testing and servicing of monitoring equipment A separate certification or report must be prepared for each monitoring systern control panel by the technician who performs the work.A copy of this form must be provided to the tank system owner/operator.The owne.11operator must submit a copy of this form to the local agency regulating UST systems within 30 days or test dale. A. General Information Facility Name TIWANA GAS Bldg.No.: Site Address: 1210 E. HAMMER LANE City: STOCKTON Zip: 95213 Facility Contact Person: Contact Phone No.: Make/Model of Monitoring Systern: VE DER ROOT TLS-350 Date of Testirg,'Servicing: 6113/2016 B. Inventory of Equipment TeslediCertified Check the ageroeriate boxes to indicate specific equiernent ins e2c edi'serviced: Tank ID: 87 Tank Size: Tank ID: 89 Tank Size: N In-Tank Gauging Probe, Model! N1 A CT 2 0 In-Tank Gauging Probe. Model: MAG 2 0 AnnLiar Space or Vault Sensor. Model: 420 29 Annutar Space or Vault Sensor. Model: 420 19 Piping Sump I Trench Sensor(s). Model: 208 21 Piping Sump/Trench Senscr(s). Model: 208 0 Fill Sump Sensor(s). Model: 209 0 Fill Sump Sensor(s). model: 208 N Mechanical Line Leak Detector. Model: FX-1 V 0 Mechanical Line Leak Detector model: 99 LD 2000 E] Electronic Line Leak Detector Model: C Electronic Line Leak Detector. Model- ❑ Tank Overfill/High-Level Sensor. Model: 0 Tank Over'iff(High-Level Sensor. Model: ❑ Cther(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: Tank Size: Tank ID: 91 Tank Size: 0 Ir-Tank G31-ging Probe. Model: 9 In-Tank Gauging Probe- IVode[:M A G 2 E] Annular Space orVault Sensor. Model: CK Annular Space or Vault Sensor. Model:4 2 0 [] Piping Sump/Trench Sensor(s), Model: 9 Piping Sump!Trench Sensor(s). Model:2 0 8 El Fill Sump Sensor(s). Model: Z Fill Sump Sensor(s), Model-2 0 8 [] Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Mode-1:99 LD 2000 0 Electronic Line Lea<Detector. Model. Ej Electronic Line Leak Detector. Model: [] Tank Overfill'High-Level Sensor. Model: [:1 Tan,<Overfill i High-Level Sensor. Model: E] Other(specify equipment type and model in Section Eon Page 2). [1 Other(specify equipment type and model in Section E on Page 2). Dispenser 1D: I / 2 Dispenser ID: 3 / 4 [I Dispenser ContainrnertSersor(s). Model: 0 Dispenser Containment Sensor(s). Model: 0 ShearValve(s). 0 Shear Valve(s). 0 Dispenser Containment Ftoat(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). ' Dispenserlit): 5 / 6 Dispenser to: 7 / 8 E] Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 1K Shear Valve(s). ShearValve(s). Z Dispenser Containment Ficat(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser to: El Dispenser Containment Cl Dispenser Containment Serisor's). Model: Sensor(s). Model: E] Shear Valve(s). ❑Shear Valve(s). [I Dispenser Containment Float(s)and Cllhain(s). ❑Dispenser Containment Float(s)and Chain(s). If the facility contairs more tanks or dispensers.copy this fem-. Include information`or every tank and dispenser at the facility. C.Certification-I codify that the equipment identified in this document was inspecied/serviced in accordance with the manufacturers' guidelines.Attached to this Certification is information(e.g.manufacturers'checklists)recessaryto 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 jilme j1pply): 0 System set-up Z Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A28A46 Licarse No 04-1676 — Testing Company Name: A-FFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2"'STREET GALT,CA95632Date of TestinglServ[cing: 6113/2016 Monitoring System Certification Page I of 4 2/21/07 Received Time Ju1- 25. 2018 10 :46AM No- 3918