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R W " Appendix VI MONITORING SYSTEM CERTIFICATION ; For Use By All Jurisdictions Within the State of California NT Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulaions 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 UST systems within 30 days of test date. A. General Information Facility Name: Site Address: EL DORADO GAS 1605 S EL DORADO ST City: STOCKTON Bldg. No.: Zip: 95206 Facility Contact Person: Aziz Contact Phone No.: (209) 939-1906 Make/Model of Monitoring System: VR TLS 350 Date of Testing/Servicing: 5-16-17 B. Inventory of Equipment Tested/Certified Check the annrnnriate hnxes to indicate snecific eauinment inspected/serviced: Tank ID: 87 DAVE WINKLER Signature: Tank ID: 91 ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 SPLIT W 87 ® Piping Sump / Trench Sensor(s). Model: 205 ® Piping Sump / Trench Sensor(s). Model: 205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. 99LD2000 ® 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). TanklD: TanklD: ❑ 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 Sensor(s). 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). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 El Dispenser Containment Sensor(s). Model: 001 ® Dispenser Containment Sensor(s). Model: 001 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). DispenserlD: 5-6 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 001 ❑ 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). FISPenserlD: 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). ,it the facility contains more tanks or dispensers, copy this form. Include intormatlon for every tank and dispenser at the tacility. 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; (check all that apply): ® System set-up ® Alarm history report Technician Name (print): DAVE WINKLER Signature: Certification No.: 5273934 -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: 5-16-17 Monitoring System Certification Page 1 of 4 2/21/07