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C, �- -Ok lei Appendix VI MONITORING SYSTEM CERTIF"T110R.,"", For Use By All Jurisdictions Within the State of Cal"mia, Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, 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 owner/operator. 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 N.— SAN JOAQUIN DOWN TOWN GARAGE Bldg. No.: Site Addrpqq- 121 S SAN JOAQUIN ST City: STOCKTON CA Zip: Facility Contact Pprqnn- Contact Phone No.: (209) 468-2068 Make/Model of Monitoring System: VEEDER ROOT TILS 360 Date of Testing/Servicing: 730-2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate s ci ic e uipment inspected/serviced: Tank ID: 87 Tank ID: • In-Tank Gauging Probe. Model: MAG I [I In-Tank Gauging Probe. Model: • Annular Space or Vault Sensor. Model: 409 [1 Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s). Model: 208 [1 Piping Sump/ Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 208 [1 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: LD-2000 ❑ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: * VAPOR POT. Model: 420 ❑ Tank Overfill / High-Level Sensor. Model: * Other (specify equipment type and model in Section E on Page 2). El Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: [I In-Tank Gauging Probe. Model: [I In-Tank Gauging Probe. Model: [I Annular Space or Vault Sensor. Model: [] Annular Space or Vault Sensor. Model: [I Piping Sump / Trench Sensor(s). Model: 0 Piping Sump / Trench Sensor(s). Model: [3 Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: [I Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: [I Tank Overfill / High-Level Sensor. Model: [I Tank Overfill / High-Level Sensor. Model: 0 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). Dispenser ID: 1 Dispenser ID: • Dispenser Containment Sensor(s). Model: 205 [] Dispenser Containment Sensor(s). Model: • Shear Valve(s). El Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). [I Dispenser Containment Float(s) and Chain(s). Dispenser ID: 2 Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 206 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). El Dispenser Containment Float(s) and Chain(s). [] Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: [] Dispenser Containment [:1 Dispenser Containment Sensor(s). Model: Sensor(s). Model: [:1 Shear Valve(s). El Shear Valve(s). [3 Dispenser Containment Float(s) 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 -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 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): 0 System set-up 0 Alarm history report Technician Name (print): DAVID WINKLER Signature: Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2no STREET GALT, CA 95632 Date of Testing/Servicing: 7-30-13 Monitoring System Certification Page I of 4 2/21/07 C, �- -Ok