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Appendix VI MONITORING SYSTEM CERTIFICATION' For Use By All Jurisdictions Within the State of California i f Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations Au 7 ?018 This farm 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 ENVIRONMENTAL 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. F-lEA.LT!-I DEPARTMENT A. General Information Facility Name: COUNTRY MARKETPLACE Bldg. No.: Site Address: 1789 W CHARTER WAY City: STOCKTON Facility Contact Person: TJ Contact Phone No.: (209) 535-1096 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 03-28-18 B. Inventory of Equipment Tested/Certified rhnrir 4hc nnnrnnrinfa hnrpg to inrlirntp gnprifir. pnuinmpnt 1nsnerted/seryiced: 'If the facility contains more tanks or dispensers, copy this form. Include information for every TanklD: 91 TankiD: 87 N In -Tank Gauging Probe. Model: MAG 2 ® In -Tank Gauging Probe. Model: MAG 2 N Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 N Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump/ Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: N Mechanical Line Leak Detector, Model: 99 LD 2000 N Mechanical Line Leak Detector, Model: RED JACKET ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: N Tank Overfill / High -Level Sensor, Model: 90% N Tank Overfill / High -Level Sensor. Model: 90% ❑ 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 ID: ❑ 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: 34 Dispenser ID: 1-2 N Dispenser Containment Sensor(s). Model: 011 N Dispenser Containment Sensor(s). Model: 011 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 N Dispenser Containment Sensor(s). Model: 011 N Dispenser Containment Sensor(s). Model: 011 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Dispenser ID: 940 Dispenser ID: 11-12 ® Dispenser Containment N Dispenser Containment Sensor(s). Model: 011 Sensor(s). Model: 011 N ShearValve(s). ® ShearValve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). tank and dispenser at the tacuity. 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): FELIX RAMIREZ Certification No.: 883072 -UT Testing Company Name: AFFORDA-TEST Testing Company Address: 416 2n1 STREET GALT, CA 95632 Signature: License No: 08-1740 Phone No. (209) 744-0113 Date of Testing/Servicing: 03-28-18 Monitoring System Certification Page 1 of 4 2/21/07