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Appendix V1 MONITORING SYSTEM CERTIFICATION For Use By Ali 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 This farm 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 ownerioperator.The owner/operator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. A. General Information Facility Name: GRUPE AIR Bldg.No.: Site Address: 5000 S LINDBERGH City, STOCKTON CA Zip: Facility Contact PAr.qnn- MAURICE Contact Phone No.: Make/Modei of Monitoring System: VEEDER ROOT Date of Testing/Servicing: 12-6-2013 B. Inventory of Equipment Tested/Certified Check the amoEnate boxes to indicate specific equipment ins pec ollserviced: Tank ID: JET FUEL Tank ID: [I In-Tank Gauging Probe. Model: (3 In-Tank Gauging Probe. Model: • Annular Space or Vault Sensor. Model: LS-01 0 Annular Space or Vault Sensor. Model: • Piping Sump/Trench Sensor(s). Model: LS4 [I Piping Sump/Trench Sensor(s). Model: [3 FIN Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: FXIV 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill I High-Level Sensor. Model: r_1 Other(specify equipment type and model in Section E on Page 2). [3 Other(specify equipment type and model In Section E on Page 2). Tank ID: Tank ID: NA 0 In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: [3 Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: [I Piping Sump/Trench Sensor(a). Model: [3 Piping Sump/Trench Sensor(s). Model: [I Fill Sump Sensor(s). Model: [3 Fill Sump Sensor(s). Model: 0 Mechanical Una Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: [3 Tank Overfill/High-Level Sensor. Model: [3 Tank Overfill/High-Level Sensor. Model: [3 Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E an Page 2). Dispenser ID: Dispenser 10: 0 Dispenser Containment Sensor(s). Model: E3 Dispenser Containment Sensor(s). Model: [3 ShearVaK*s). El ShearValve(s). [3 Dispenser Containment Float(s)and Chaln(s). [3 Dispenser Containment Floats)and Chaln(s). Dispenser 10: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: [I Shear Valve(s). 0 Shear Valve(s). [3 Dispenser Containment Float(s)and Chaln(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: [I Dispenser Containment 0 Dispenser Containment Sensor(s). Model: Sensor(s). Model: [3 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Floags)and Chain(s). [I 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 monitorin quipment.For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): usystern set-up [3 Alarm history report Technician Name(print): DAVE WINKLER Signature: 1�3' Certification No.: 6263373-UT — License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 -STREET GALT,CA 95632 Date of Testing/Servicing: 12-6-2013 Monitoring System Certification Page 1*1`4 =1/07 RECFIVED DE 0 2016 ENVIRONMENTAL HEALTH DEPARTMENT