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RECEIV�b` JAN 3 0 2017 Appendix Vi 40 MONITORING SYSTEM CERTIFICATION °� -�' For Use By All Jurisdictions Within the State of California Aut './, 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: CRAG - PACIFIC AVE CHEVRON Bldg. No.: Site Address: 6633 PACIFIC AVE. City: STOCKTON zip: 95207 Facility Contact Person: CRM Contact Phone No.: 209-477.4294 Make/Model of Monitoring System: VEEDER ROOT TLS -350 Date of Testing/Servicing: 1/23/2017 B. Inventory of Equipment Tested/Certified nL��1- a1-. � � l-�.-�� .J:..6. .. ..:di.. w r4 i wbeelrwo•liiwnla• Tank ID: 91 Tank Size: Tank ID: 87 - 2 Tank Size: ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 7 ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump / Trench Sensor(s). Model: 3 5 2 ® Piping Sump / Trench Sensor(s). Model: 3 5 2 ® 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: P L L D - 8 4 8 4 ❑ Electronic Line Leak Detector. Model: SHARED W/ 87-1 ® 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 - 1 Tank Size: Tank ID: Tank Size: ® In -Tank Gauging Probe. Model: MAGI ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 407 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 3 5 2 ❑ 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: ® Fiectronic Line Leak Detector. Model: P L L D - 8 4 8 4 ❑ Electronic Line Leak Detector. Model: 0 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: i / 2 Dispenser ID: 3 / 4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® 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: 11 / 12 ® Dispenser Containment ® Dispenser Containment Sensor(s). Model: 2 0 8 Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). 9f the facility contains more tanks or dispensers, copy mis toren. mcivae mrormauon Tor every rank anu uis�enbw ei uw IaunLy. 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): ZANE NIMMO Signature: — --Z_ Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2nd STREET GALT, CA 95632 Date of Testing/Servicing: 1/23/2017 Monitoring System Certification Page 1 of 4 2/21/07