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Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Witt in 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 slp arate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy thisformmust be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agencygulating UST systems within 30 dans of test date. A. General information Tank Size: Facility N.M.. KISHIDA TRUCKING ui Model: Site Model:] Adrirr?cs• 1725 ACKERMAN RD. C Facility Contact Model: PPrenn- KELLY Model: Make/Model of Monitoring System: OMNTEC OEL800 Model: �I B. Inventory of Equipment Tested/Certified Model: Check the ap ro riate boxes to indicate specific equi ment Inspected/se Tank ID: NORTH DIESEL Tank Size: Tani ® In -Tank Gauging Probe. Model: MAG ❑ In ® Annular Space or Vault Sensor. Model: ILS ❑ Ai ® Piping Sump / Trench Sensor(s). Model: EIS ❑ pi ❑ Fill Sump Sensor(s). Model: ❑ Fi ® Mechanical Line Leak Detector, Model: FX 1VD ❑ M, ❑Electronic Line Leak Detector. Model: ❑ Ei, ❑ Tank Overfill / High -Level Sensor. Model: ❑ T2 ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Ot Tank ID: SOUTH DIESEL Tank Size: Tankl ® In -Tank Gauging Probe, Model: MAG ❑ Inj ® Annular Space or Vault Sensor. Model: SAME TANK ❑ An ® Piping Sump / Trench Sensor(s). Model: EIS ❑ pig ❑ Fill Sump Sensor(s). Model: ❑ Fii� ® Mechanical Line Leak Detector. Model: FX 1VD ❑ Mo ❑ Electronic Line Leak Detector. Model: ❑ El� ❑ Tank Overfill / High -Level Sensor. Model: ElOther (specify equipment type and model in Section E on Page 2). ❑ Tai ❑ Ott Dispenser ID: NORTH Dispe ❑ Dispenser Containment Sensor(s). Model: ❑ Disj ® Shear Valve(s). ® Sh4 ® Dispenser Containment Float(s) and Chain(s). ® Disi Dispenser ID: SATELITE Dispe ❑ Dispenser Containment Sensor(s). Model: ❑ Di D's ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ®Sh and Chain(s). Cl Dis Dispenser ID: Dispe ❑ Dispenser Containment Sensor(s). Model: ❑ Dis (D Shear Valve(s). Se ®Sh9 ❑ Dispenser Containment Float(s) and Chain(s). "If ❑ Dis the facility contains more tanks or dispensers, copy this form. Include information for every to Bldg. No.: LODI, CA Zip: 95240 Contact Phone No.: ( 1 Date of Testing/Servicing: 11/10/2010 ID: Tank Size: Tank Gauging Probe. ui Model: anular Space or Vault Sensor. Model:] )Ing Sump / Trench Sensor(s). Model: I Sump Sensor(s). Model: !chanical Line Leak Detector. Model: :ctronic Line Leak Detector. Model: �I nk Overfill / High -Level Sensor. Model: ier (specify equipment type and model in Section E on Page 2). ID: Tank Size: rank Gauging Probe, Model: 111 iular Space or Vauit Sensor. Model: Ing Sump / Trench Sensor(s). Model: Sump Sensor(s). Model: :hanical Line Leak Detector. Model: :ironic Line Leak Detector. Model: k Overfill / High -Level Sensor. Model: ar (specify equipment type and model in Section E on Page 2). iser ID: SOUTH censer Containment Sensor(s). Model: 3r Valve(s). enser Containment Float(s) and Chain(s). iserID: enser Containment Sensor(s). Model: it Valve(s). :nser Containment Float(s) and Chain(s). ser ID: enser Containment sor(s). Model: ar Valve(s). enser Containment Float(s) and Chain(s). k and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was Inspected/servibed 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 he G s T r 1 copy of the report; (check all that apply): ® System set-up ® Alarm history sport u F Technician Name (print): ZANE A NIMMO Signatur : >� r t� xeR Certification No.: A28446 License Testing Company Name: AFFORDA-TEST Phone P Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Monitoring System Certification Page 1 of 4 a'wpr ask 41'x/0