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Appendix VI MONITORING SYSTEM CERTIFICATION �� 2015 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 m r UNMENTAL each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to th&WWrk Vr CDAQTAfir:KI - 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: PARKWOODS SHELL Site Address: 1612 W. HAMMER LN. Bldg. No.: city: STOCKTON Zip: 95209 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS -350 Date of Testing/Servicing: 5/7/2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tank Size: Tank ID: Tank Size: ® In -Tank Gauging Probe. Model: MAG 2 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump /Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ 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 Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank Size: Tank ID: 91 Tank Size: ® In -Tank Gauging Probe. Model: MAG 2 ® in -Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: SAME VESSEL ® Piping Sump / Trench Sensor(s), Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ 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 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: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Vaive(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ ShearValve(s). ❑ ShearValve(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 Certification No.: A28446 Testing Company Name: AFFORDA-TEST Testing Company Address: 416 2 STREET GALT, CA 95632 Signature: 2 -- License No: 04-1676 Phone No. _(209) 744-0113 Date of Testing/Servicing: 5/7/2015 Monitoring System Certification Page 1 of 4 2/21/07