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I , • 0 �a: R4KSted 87 STP Sensor wit inspector John 01__ Appendix VI Model: MAG 1 ® Annular Space or Vault Sensor. MONITORING SYSTEM CERTIFICATION 420 ® Piping Sump / Trench Sensor(s). Model: For Use By All Jurisdictions Within the State of California ® Fill Sump Sensor(s). Model: 208 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulatimoi a C 99 LD 2000 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for° zn l!1 each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system The this form to the local agency regulating UST systems within 30 days of test date. FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Tank Overfill / High -Level Sensor. Model: owner/operator. owner/operator must submit a copy of ❑ Other (specify equipment type and rnodel in Section E on Page 2). II II ❑ Other (specify equipment type and model in Section E on Page 2). lillll A. General Information O Facility Name: LODI PAC PRIDE Bldg. No.: j n Site Address: 351 N BECKMEN RD City: LODI Zip: 95240 Facility Contact Person: TED Contact Phone No.: ( ) 06-27-17 & Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 8-8-17 B. Inventory of Equipment Tested/Certified the aoorooriate boxes to indicate Tank ID: 87 �a: R4KSted 87 STP Sensor wit inspector John ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: RED DIE �a: R4KSted 87 STP Sensor wit inspector John ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: FE PETRO ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: 91 �a: R4KSted 87 STP Sensor wit inspector John ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DIESEL �a: R4KSted 87 STP Sensor wit inspector John ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump/ Trench Sensor(s). Model: 420 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: FE PETRO ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). `Tank �a: R4KSted 87 STP Sensor wit inspector John ID: DIESEL 2 ® In -Tank Gauging Probe. Model: MAG 1 JiWa apcne It e. -All test pa "d ,A Annular Space or Vault Sensor. Model: ❑ Annular Space or It Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Tre nsor(s . Model: ® Fill Sump Sensor(s). Model: 208 F�ttil seoTr,(s Model: ® Mechanical Line Leak Detector. Model: RED JACKET W 1n�q ISI chanica"Y ine Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and rnodel in Section E on Page 2). II II ❑ Other (specify equipment type and model in Section E on Page 2). lillll Dispenser ID: 1-2 ® Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). 208 Dispenser ID: 5-6 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9-10 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Model: 208 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: VENT BOX ® Dispenser Containment Sensor(s). Model: 208 ❑ Shear Valve(s). 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 verity that this information is correct and a Plot Pian 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): FELIX RAMIREZ Signature: 11: Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2n° STREET GALT, CA 95632 Date of Testing/Servicing: 06-27-17 Monitoring System Certification Page 1 of 4 2/21/07