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il Appendix VI F.EB 0 1 2017 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, Cal oEA LTH This form must be used to document testing and servicing of monitoring equipment. A separate certification or report m@ ERAiPWMENT 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: SHOP N GO Bldg. No.: Site Address: 4511 PACIFIC AVE. City: STOCKTON Facility Contact Person: MO Contact Phone No.: Zip: 95207 Make/Model of Monitoring System: VEEDER ROOT TLS -350 Date of Testing/Servicing: 5/10/2016 B. Inventory of Equipment Tested/Certified f`hark tha nnnrnnrinta hnvac to indirata cnarifir anuinmr:nt incnartarl/carviraA- Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: ® In -Tank Gauging Probe. Model: MAG 7 ® In -Tank Gauging Probe. Model: MAG 7 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 2 0 8 ® Piping Sump / Trench Sensor(s). Model: 2 0 8 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: F X - I V D ® 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). Tank ID: Tank Size: Tank ID: Tank Size: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ 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 Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). DispenserlD: 1/2 Dispenser ID: 3/4 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). DispenserlD: 5/6 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 208 ❑ 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 ❑ Dispenser Containment Sensor(s). Model: 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 tortn. Include intormation for every tanK ana aispenser at me racmty. C. Certification -1 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: ,°' e -.tea Certification No.: A28446 License No: 04--1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 4162 Id STREET GALT, CA 95632 Date of Testing/Servicing: 5/10/2016 Monitoring System Certification Page 1 of 4 2/21/07