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•► t< Appendix VI 01 V 2 4 2v(-, E� ,_ _ 1�lG SYSTEM CERTIFICATION �J All Jurisdictions Within the State of California Authority Cited: Chapter 6.7�, Code; Cha ter 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. q 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. General Information Facility N.— KISF Site Arlrfraac' 1726 Facility Contact TRUCKING ACKERMAN City: LODI Bldg. No.: Zip: Percnn- KELLIE Contact Phone No.: 209 368-0603 Make/Model of Monitoring System: OMNTEC OEL 8000 Date of Testing/Servicing: 11/6/2009 B. Inventory of Equipment Tested/Certified Check the annronriatp hnxpc to inrii—#. Tank ID: DIE - Tank ID: DIE ® in -Tank Gauging Probe, Model: MAG ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: ILS ® Annular Space or Vault Sensor. Model: ILS ® Piping Sump / Trench Sensor(s). Model: ULS ® Piping Sump/ Trench Sensor(s). Model: ULS ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FX1V ®Mechanical Line Leak Detector. Model: FX1V ❑ 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 ID: ❑ 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). Dispenser ID: NORTH DIESEL. Dispenser ID: SOUTH DIESEL ❑ 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: SOUTH DIESEL. SATELITE I Dispenser ID: ❑ 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). DispenserID: Dispenser ID ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). j ❑ Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). El Dispenser Containment Float(s) and Chain(s). 'If the faoility rmtainc --ry ., .,,vwc � avciy :a:in dnu oispenser at the tacillty. 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 applv): ❑ System set-up ❑ Alarm, history report Technician Name (print): FELIX RAMIREZ Signature: Certification No.: B34976 license No: 5273934 -UT 08-1740 OTTL -- Testing Company Name: AFFOR C)AJEST phone No. _(209) 744-0113 _ Testing Company Address: 416 2" STREET GALT, CA 95632 bate of Testing/Servicing: 11-06-09 _ — Monitoring System Certification Page 1 of 4 2/21/07