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Appendix VI RECEIVED MONITORING SYSTEM CERTIFICATION APR 0 9 201 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 of Regulations This forth must be used to document testing and servicing of monitoring equipment.A separate certification or report must be pr p�Le VROOMTAL or each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank Ot�rr{TH n} PA RTRA T 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: FLAG CITY SHELL Bldg.No.: Site Address: 6437 W BANNER RD City: LODI CA Zip: 96240 Facility Contact Person, Contact Phone No.: ( ) Make/Model of Monitoring System: GILBARCO EMC Date of Testing/Servicing: 3/26/18 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicates ecific a ui ment ins ected/serviced: Tank ID: 87 Tank ID: 91 N In-Tank Gauging Probe. Model: MAG 1 N In-Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model: 460 N Annular Space or Vault Sensor, Model: 460 N Piping Sump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 991d 2000 N 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). Tank ID: DSL TanklD: N In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: SPLIT W 91 ❑ Annular Space or Vault Sensor. Model: N Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 99LD 2000 ❑ 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: 5-6 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: N Shear Valve(s). N Shear Valve(s). N Dispenser Containment Float(s)and Chain(s). N Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: N Shear Valve(s). N Shear Valve(s). N Dispenser Containment Float(s)and Chain(s). N Dispenser Containment Float(s)and Chain(s). DispenserlD: 9-10 DispenserlD: 11-12 ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: N Shear Valve(s). ®Shear Valve(s). N 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 Pian 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.: 8883059-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date of Testing/Servicing: 3-26-2018 Monitoring System Certification Page 1 of 4 2/21/07