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w � t p , -�4 i =D Appendix VI�," MONITORING SYSTEM CERTIFICATION %UCa `�. 2.01 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 must be prepared forr� s each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank s 1 R0 N I�'? E � A HEALTH owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of est date. M E �T IEp � A. General Information Facility Name: LODI PAC PRIDE Bldg. No.: 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 cnecK tnelppropriate noxes to mai cate s eanc a ut ment inspect aiservicea: Tank ID: 87 ® In -Tank Gauging Probe. Model: Tank ID: 91 abHapglwenlbi;�.All test pamed ® Annular Space or Vault Sensor. ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ID Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® 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: FLAPPER ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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: RED DIE Tank ID: DIESEL ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 420 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: FE PETRO ® Mechanical Line Leak Detector. Model: FE PETRO ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). 1 ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DIESEL 2 �a: Rq Xsted 87 STP Sensor wi inspector Jo n ® In -Tank Gauging Probe. Model: MAG 1 abHapglwenlbi;�.All test pamed ® 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 Sum Sensor(s). P�d Model: 208 Fil sor s Model: i;awler( ® Mechanical Line Leak Detector. Model: RED JACKET echamca ine Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ElTank Overfill / High -Level Sensor. Model: [IOther (specify equipment type and model in Section E on Page 2). [I Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® 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 Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9-10 Dispenser ID: VENT BOX ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ❑ Shear Valve(s). ns 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): FELIX RAMIREZ Signature: n� Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113744-0113 Testing Company Address: 416 2nd STREET GALT, CA 95632 Date of Testing/Servicing: 06-27-17 Monitoring System Certification Page 1 of 4 2/21/07