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1 k RECEIVED Appendix VI APR MONITORING SYSTEM CERTIFICATION 201$ 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 �� This form must be used to document testing and servicing of monitoring equipment.A separate certification or report m „pry re or each monitoring system control panel by the technician who performs the work.A copy of this form must be provided t k�fakl s rPA T ENT 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: COUNTRYSIDE LIQUOR Bldg.No.: Site Address: 14971 N HWY 88 City: LODI CA Zip: 95240 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: Date of Testing/Servicing: 3/29/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins ected/serviced: Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: ® In-Tank Gauging Probe. Model: MAG 2 ® In-Tank Gauging Probe. Model: MAG 2 N Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: SPLIT ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: STP MLD ® Mechanical Line Leak Detector. Model: 99LD 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: DIE Tank Size: Tank ID: Tank Size: ® In-Tank Gauging Probe. Model: MAG 2 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: SPLIT ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ 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: ® Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑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-1 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 Pian 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): David Winkler Signature: V Certification No.: 8883059-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date of Testing/Servicing: 3-29-2018 Monitoring System Certification Page 1 of 4 2/21/07