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RE ""D Appendix VI CEI" MONITORING SYSTEM CERTIFICATION JUN 018 For Use By All Jurisdictions Within the State of California 19 2 Authority Cited:Chapter 6.7,Health and Safety Code; Chapter 16,Division 3,Title 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report mZ W,. WMENTAL each monitoring system control panel by the technician who performs the work.A copy of this form must be provid, F"A 9 IaRTI+4ENT owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems with n dkys of fest'ate: A. General Information Facility Name: SYSTEM TRANSPORT Bldg.No.: Site Address: 707 E. ROTH ROAD city: FRENCH CAMP Zip: 95231 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS-300C Date of Testing/Servicing: 5/30/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: DSL 2 Tank Size: 12 K Tank ID: Tank Size: ® In-Tank Gauging Probe. Model: M A G 2 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 4 0 9 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 2 0 8 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 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). 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 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: SATELITE I Dispenser ID: ® Dispenser Containment Sensor(s). Model: 2 0 8 ❑ Dispenser Containment Sensor(s). Model: ® ShearValve(s). ❑ ShearValve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: I / 2 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 2 0 8 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ ShearValve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: SATELITE 2 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 2 0 8 ❑ Dispenser Containment Sensor(s). Model: ® ShearValve(s). ❑ ShearValve(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;(check all thatapply): ®System set-up ®Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 21d STREET GALT,CA 95632 Date of Testing/Servicing: 5/30/2018 Monitoring System Certification Page 1 of 4 2/21/07