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Appendix VI i d " D MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California 9 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 prep�,UWRONMIENTAL HEALTH each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system 0 FV\F1'T'M,,E. owner/operator.The owner/operator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. A. General Information Facility Name: —ONE STOP MARKET Bldg.No.: Site Address: 1161 W LOUISE AVE City: MANTECA Zip: 95336 Facility Contact Person: HARI Contact Phone No.: (209)823-4081 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 12-04-17 B. Inventory of Equipment Tested/Certifled Check the=!p yrogriate boxes to indicate sp22"uIpment ins pec ed/serviced: TankID: 87 TankID: 91 • In-Tank Gauging Probe. Model: MAG 1 0 In-Tank Gauging Probe. Model: MAG 1 • Annular Space or Vault Sensor. Model: 409 0 Annular Space or Vault Sensor. Model: 409 • Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208 [I Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 99 LD 2000 Mechanical Line Leak Detector. Model: 99 LID 2000 0 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: FLAPPER Tank Overfill I High-Level Sensor. Model: FLAPPER [I Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Tank ID: DIESEL TankID: • In-Tank Gauging Probe. Model: MAG 1 [1 In-Tank Gauging Probe. Model: • Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: • Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: [I Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: ED Mechanical Line Leak Detector. Model: 99 LID 2000 ❑ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ Tank Overfill/High-Level Sensor. Model: [I Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 0 Dispenser Containment Sensor(s). Model: 208 ID Dispenser Containment Sensor(s). Model: 208_ ED ShearValve(s). 0 ShearValve(s). [I Dispenser Containment Float(s)and Chain(s). [I Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser I D: _7-8 * Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 208 * ShearValve(s). 0 ShearValve(s). * Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment 0 Dispenser Containment Sensor(s). Model: Sensor(s). Model: [I ShearValve(s). ❑Shear Valve(s). El Dispenser Containment Float(s)and Chain(s). El 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): E]System set-up El Alarm history report Technician Name(print): Signature: Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date of Testing/Servicing: 12-04-17 Monitoring System Certification Page 1 of 4 2/21/07