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REGiIVED DEC, 2 9 20116 Appendix VI W( A HEALTH MONITORING SYSTEM C 1 1 �WIIENT For Use By All Jurisdictions Within the State of I'd ' 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 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 ownerloperetor.The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: GRUPE AIR Bldg.No.: Site Address: 5000 S LINDBERGH City: STOCKTON Zip: Facility Contact Person: MAURICE Contact Phone No.: (209)473-6204 Make/Model of Monitoring System: UNIVERSAL SENSOR DEVICES Date of Testing/Servicing: 12/18/2015 B. inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecifie equipment ins ectad/serviced: TankID: JET-A Tank Size: Tank ID: Tank Size: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: LS-01 ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: LS-1 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sennsogs). Model: ® Mechanical Une Leak Detector. Model: FXIV ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Madel: ❑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 We and model in Section E on Page 2). Tank ID: Tank Size: Tank ID: Tank Size: ❑ In-Tank Gauging Probe. Model: ❑ in-Tank Gauging Probe. Model: ❑Annuter Space or VauR Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ FBI Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Cl Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(spectry equipment type and model in Section E on Page 2). ❑ Ogler(specify equipment type and model In Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Disperser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Flost(s)and Chaln(s). DispenserD: Dispenser ID: Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chaln(s). ❑ Disperser Containment Float(s)and Chain(s). Dispenser ID: DispenserlD: ❑Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Val*s). ❑Shear Valve(s). ❑ Dispenser Containment Floats)and Chaln(s). ❑Dispenser Containment Float(s)and Chain(s). 'I(the facility contains more tanks or dispensers,copy this form. Include Information every tank and dispenser at the facility. C.Certification-I certify that the equipment identified In this document was Inspectediserviced 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 monitoringequipment.For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): System sat-up ❑Alarm history report Technician Name(prir ft Ed Stearns Signature: ,. Certification No.: A31048 License No: Testing Company Name: AFFORDA-TEST Phone No. _(209)744.0113 Testing Company Address: 416 2a°STREET GALT CA 95632 Date of Tesdng/Servidng: 12/18/15 Monitoring System Certification Page 1 of 4 2/21/07