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Appendix VI MONITORING SYSTEM CERTIFICATION 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 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: ELDORADO FOOD MART Bldg. No. : Site Address: 2320 N . EL DORADO ST. city: STOCKTON zip: 95204 Facility Contact Person: BOB , KATHY , & KELLY Contact Phone No. : ( ) Make/Model of Monitoring System: VEEDER ROOT SIMPLICITY Date of Testing/Servicing : 2/ 13/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced : Tank ID : 91 OCT Tank Size : 12 K Tank ID: 87 OCT Tank Size: 12 K N In-Tank Gauging Probe, Model: M A G 7 N In-Tank Gauging Probe, Model: MA G I N Annular Space or Vault Sensor, Model: 3 0 2 N Annular Space or Vault Sensor, Model : 3 0 3 N Piping Sump / Trench Sensor(s). Model: 3 5 2 N Piping Sump / Trench Sensor(s), Model : 3 5 2 ❑ 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: P L L D - 8 4 8 4 N Electronic Line Leak Detector, Model : P L L D - 8 4 8 4 ❑ 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 : DIESEL Tank Size: 12 K Tank ID: Tank Size: N In-Tank Gauging Probe, Model: M A G I ❑ In-Tank Gauging Probe, Model : N Annular Space or Vault Sensor, Model: 3 0 2 ❑ Annular Space or Vault Sensor. Model : N Piping Sump / Trench Sensor(s), Model: 3 5 2 ❑ 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: N Electronic Line Leak Detector, Model: P L L D - 8 4 8 4 ❑ 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 ❑ 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). I Dispenser ID : . 5 / 6 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). Dispenser ID : Dispenser ID : ❑ Dispenser Containment Sensor(s). Model : ❑ 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). `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 that apply) : ® System set-up ® Alarm history report Technician Name (print): ZANE NIMMO Signature: + i Certification No. : A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. 209 744-0112 Testing Company Address: 416 2nd STREET GALT, CA 95632 Date of Testing/Servicing: 213/2018 5 20191 Monitoring System Certification Page 1of4 ENVIRONr�� E XCHEALTH CIKV DEPARTMENT