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Appendix VI IUL 17 MONITORING SYSTEM CERTIFICATION j 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 CCd# jff'lons This form must be used to document testing and servicing of monitoring equipment.A separate certification or repok9_A16Ti,�.P)M;b each mo nitoring 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 LIST systems within 30 days of test date. A. General Information Facility Name: TIWANNA GAS Bldg.No.: Site Address. 1210 E. HAMMER LANE city: STOCKTON Zip: 95213 Facility Contact Person: Contact Phone No.: ( Make/Model of Monitoring System: GILBARCO E M C Date of Testing/Servicing: 6/29/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment inspected/serviced: Tank ID: 87 OCT Tank Size: 12 K Tank ID: 89 OCT Tank Size: 10 K Z In-Tank Gauging Probe. Model: M A G 2 0 In-Tank Gauging Probe. Model: M A G 2 Z Annular Space or Vault Sensor. Model: 4 2 0 Z Annular Space or Vault Sensor. Model. 4 2 0 0 Piping Sump/Trench Sensor(s). Model: 2 0 8 rD Piping Sump/Trench Sensor(s). Model: 2 0 8 0 Fill Sump Sensor(s). Model: 2 0 8 0 Fill Sump Sensor(s). Model: 2 0 8 0 Mechanical Line Leak Detector. Model: 99 LD 2000 0 Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: M A G 2 Z Tank Overfill/High-Level Sensor. Model: M A G 2 El Other(specify equipment type and model in Section E on Page 2). [1 Other(specify equipment type and model in Section E on Page 2). Tank ID: 91 OCT Tank Size: 10 K Tank ID: Tank Size: • In-Tank Gauging Probe. Model: M A G 2 El In-Tank Gauging Probe. Model: • Annular Space or Vault Sensor. Model: 4 2 0 El Annular Space or Vault Sensor. Model: • Piping Sump/Trench Sensor(s). Model: 2 0 8 El Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model 2 0 8 El Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: F X - I V El Mechanical Line Leak Detector. Model: E] Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model- 0 Tank Overfill/High-Level Sensor. Model: M A G 2 El Tank Overfill/High-Level Sensor. Model, El Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Dispenser ID: I / 2 Dispenser ID: 3 / 4 0 Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: 0 ShearValve(s). [K ShearValve(s). Z Dispenser Containment Float(s)and Chain(s). Z Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5 / 6 Dispenser ID: . 7 / 8 El Dispenser Containment Sensor(s). Model: E] Dispenser Containment Sensor(s). Model: ED ShearValve(s). Z ShearValve(s). 0 Dispenser Containment Float(s)and Chain(s). Z Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: El Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: 0 ShearValve(s). El ShearValve(s). [I Dispenser Containment Float(s)and Chain(s). El 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): 0 System set-up Z Alarm history report Technician Name(print): ZANE NIMMO Signature: — eqo<E] � Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 211 STREET GALT,CA 95632 Date of Testing/Servicing: 6/29/2018 Monitoring System Certification Page 1 of 4 2/21/07