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t Appendix VI =« . MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California I`Y 1, IJ 2017 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 for JH each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to th owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 oY s tlatea A. General Information Facility N,,,.,a. Quick Shop Bldg. No.: Site Address: 2072 N YOSEMITE AVE City: MANTECA CA Zip: Facility Contact Person: PETE Contact Phone No.: (209) 824-6700 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 5-1-17 B. Inventory of Equipment Tested/Certified Chark tha annrnnriata hnvas to indirate specific enuinment inspected/serviced: Tank ID: 87 Tank ID: 87 2 N In -Tank Gauging Probe. Model: MAG 1 N In -Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: SPLIT N Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD 2000 ❑ 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). Tank ID: 91 Tank ID: NA N In -Tank Gauging Probe. Model: MAG 1 X In -Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: N Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: LD 2000 ❑ 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: 1-2 Dispenser ID: 5-6 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 N Shear Valve(s). N ShearValve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). DispenserlD: 9-10 Dispenser ID: ❑ Dispenser Containment N Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: N 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 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): N System set-up N Alarm history report Technician Name (print): DAVE WINKLER Signature: s _„} Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2nd STREET GALT, CA 95632 Date of Testing/Servicing: 5-1-17 Monitoring System Certification Page 1 of 4 2/21/07