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Appendix VI MONITORING SYSTEM CERTIFICATION 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 for each monitoring system control panel by the technician who performs the work. A 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. A. General Information Facility Name: Quick Shop -GAS Bldg. No.: Site Address: 2072 N YOSEMITE AVE City: MANTECA CA Zip: 96337 Facility Contact Person: PETE Contact Phone No.: (209) 824-6700 Make/Model of Monitoring System: VEEDER ROOT TLS 360 Date of Testing/Servicing: 3-31-17 B. Inventory of Equipment Tested/Certified Tank ID: 87 Model: ® In -Tank Gauging Probe. ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump / Trench Sensogs). Model: 208 ❑ Fill Sump Sensor(s). Model: LD 2000 ® Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: 91 Model: MAG 1 ® 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: LD 2000 ® Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: 100 Model: 208 ® 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: ® Mechanical Line Leak Detector. Model: FE PETRO ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 ® Dispenser Containment Sensogs). Model: 208 ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 ® 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 ® ShearValve(s). ❑ Dispenser Containment Float(s) and Chain(s). Tank ID: 87 2 Model: ® In -Tank Gauging Probe. Model: MAG 1 ❑ Annular Space or Vault Sensor. Model: SPLIT ® Piping Sump/ Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) TanklD: DSL ® In -Tank Gauging Probe. Model: MAG 1 ❑ Annular Space or Vault Sensor. Model: SPLIT ® Piping Sump /Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). TanklD: 110 ® In -Tank Gauging Probe. Model: MAG 1 ❑ Annular Space or Vault Sensor. Model: SPLIT ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 5-6 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: _ ❑ Shear Valve(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 al( that apply): ® System set-up ® Alarm history report Technician Name (print): DAVE WINKLER Signature: %;4-Z,,_ _ _ ) Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST 416 21d St Gait 95632 Phone No. (209) 744-0112 Date of Testing : 3-31-17 Monitoring System Certification Page 1 of 4 2/21/07