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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 ownerloperator 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: 1901 EL DORADO City: STOCKTON CA Zip: 95206 Facility Contact Person: Contact Phone No. : ( ) Make/Model of Monitoring System : VEEDER ROOT TLS 350 Date of Testing/Servicing: 8/14/2018 B . Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced : Tank ID: 87 Tank Size: Tank ID : 91 Tank Size : ® In-Tank Gauging Probe . Model: MAG 1 ® In-Tank Gauging Probe . Model : MAG 1 ® Annular Space or Vault Sensor. Model: 420 SPLIT ® Annular Space or Vault Sensor. Model: 420 SPLIT ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model : 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model : ® Mechanical Line Leak Detector. Model : 99LD 2000 ® 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: 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: 1 -2 Dispenser ID : ® Dispenser Containment Sensor(s). Model: 208 ❑ 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). Dispenser ID: 34 Dispenser ID: ® Dispenser Containment Sensor(s ). Model: 208 ❑ 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). Dispenser ID : Dispenser ID: ❑ Dispenser Containment L[IDispenser Containment Sensor(s ). Model : Sensor(s) . Model : ar Valve(s). ❑ Shear Valve(s). enser 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 DAVID WINKLER Technician Name (print): Signature: \ 1 Certification No. : 8883059-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: 8-14-18 Monitoring System Certification Page 1 of 4 2/21 /07 i