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Appendix VI MONITORING SYSTEM CERTIFICATION 11,z 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 `,1 w Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be preparpd,for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank s tm ' 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 tv.`, PACIFIC AVENUE CHEVRON Bid No.: ,,, 9 Site Addreee 6633 PACIFIC AVE city: STOCKTON zip: 95207 Facility Contact Person -JOSH Contact Phone No.: (916) 947-1277 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 1/29/2018 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicatespecific a ui ment ins ectad/serviced: Tank ID: 91 Tank Size: Tank ID: 87-1 Tank Size: ® In -Tank Gauging Probe. Model: MAG -1 ® In -Tank Gauging Probe. Model: MAG -1 ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump /Trench Sensor(s). Model: 352 ® Piping Sump / Trench Sensor(s). Model: 352 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD ® 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: 87-2 Tank Size: Tank ID: Tank Size: ® In -Tank Gauging Probe. Model: MAG -1 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 407 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Senors). Model: 352 ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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: 3-4 ® Dispenser Containment Sensogs). Model: 208 er Containment Sensor(s). Model: 208 ® Shear Valve(s). alve(s). ❑ Dispenser Containment Float(s) and Chain(s). er Containment Float(s) and Chain(s). Dispenser ID: 5-6 FD!en rlD: 7-8 ® Dispenser Containment Sensor(s). Model: 208 er Containment Sensor(s). Model: 208 ® ShearValve(s). alve(s). ❑ Dispenser Containment Float(s) and Chain(s). er Containment Float(s) and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 ® Dispenser Containment ® Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 ® Shearvalve(s). ® ShearValve(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): ® System set-up ® Alarm history report Technician Name (print): Ed Steams Signature: - Certification No.: A31048 License No: Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2"d STREET GALT, CA 95632 Date of Testing/Servicing: 1/29/18 Monitoring System Certification Page 1 of 4 2/21/07