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Appendix VI MONITORING SYSTEM CERTIFICATION DEC 2 9 20t� 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 ofR`e7ulatlone T This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared 1p��'`•��` ' 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 lest 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: 12/1812016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific ui merit ins acted/serviced: Tank ID: 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 Scrods). Model: LS-1 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 19 Mechanical Line Leak Detector. Model: FXIV ❑ 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). Tank ID: Tank Size: Tank ID: Tank Size: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensors). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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). ❑ Omer(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensors). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floet(s)and Chaints). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: DlspenserlD: ❑ Dispenser Containment Sensor(s). Model. ® Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Velvets). ❑ Dispenser Containment Floats)and Chemist. ❑ Dispenser Containment Floal(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-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;(cheek all that apply): ❑System set-up ❑Alarm history report Technician Name(print): Ed Steams Signature: Certification No.: A31048 License No: Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 _ Testing Company Address: 416 2n°STREET GALT CA 95632 Data of Testing/Servicing: 12/18/15 _. Monitoring System Certification Page 1 of 4 2/21/07