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W111,11"I";', Appendix VI MONITORING SYSTEM CERTIFICATION APR '19 2017 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 AL HEALTH This form must be used to document testing and servicing of monitoring equipment. A separate certification or epare for r- each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to then , l; L. NT owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 ays of test date. A. General Information Facility Name: COUNTRY MART 76 Bldg. No.: Site Address: 34243 S CHRISMAN RD Facility Contact Person: SANDHU Make/Model of Monitoring System: VEEDER ROOT TLS 350 City: TRACY Zip: 95376 Contact Phone No.: (209) 832-8642 B. Inventory of Equipment Tested/Certified Check the appropdate boxes to indicatespecific equipment ins ected/serviced: Date of Testing/Servicing: 04-04-17 Tank ID: 87 Tank ID: 91 N In -Tank Gauging Probe. Model: MAG 1 N In -Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model: 420 N Annular Space or Vault Sensor. Model: 420 181 Piping Sump / Trench Sensor(s). Model: 208 N Piping Sump/ Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 99 LD 2000 N Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ 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: DIESEL Tank ID: DIESEL N In -Tank Gauging Probe. Model: MAG 1 N In -Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model: 420 N Annular Space or Vault Sensor. Model: 420 N Piping Sump / Trench Sensor(s). Model: 208 N Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 99 LD 2000 N Mechanical Line Leak Detector. Model: PE PETRO ❑ 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: 3-4 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: 5-6 Dispenser ID: 7-8 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: 9-10 Dispenser ID: SAT 11 ® Dispenser Containment N Dispenser Containment Sensor(s). Model: 208 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). `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): FELIX RAMIREZ Signature: a Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0112 Testing Company Address: 416 2nd STREET GALT, CA 95632 Date of Testing/Servicing: 04-04-17 Monitoring System Certification Page 1 of 2/21/07