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RECEIVED Appendix M F 6 2019 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California � � � �-i AL HEALTH Authority Cited : Chapter 6.7, Health and Safety Code , Chapter 16, Division 3, Title 23, California ' MENT This form must be used to document testing and servicing of monitoring equipments 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. Generallnformation Facility Name: TRACY UNIFIED SCHOOL DISTRICT Bldg . No.: Site Address, 1979 W. LOWELL AVENUE city: TRACY zip: 95376 Facility Contact Person: Contact Phone No.: ! ) Make/Model of Monitoring System: OPW iTouch Date of Testing/Servicing: 1 /25/2019 B , inventory of Equipment Tested/Certified Check the approoriate boxes to indicatespecific equioment ins ie /serviced: Tank ID : 87 OCT Tank Size : 10 K Tank ID: DIESEL Tank Size: 10 K * In-Tank Gauging Probe. Model: M A G ® In•Tank Gauging Probe. Model: M A G ® Annular Space or vault Sensor. Model: 3 0 - 3 2 2 1 - 1 A ® Annular space or vault sensor. Model: 3 0 - 3 2 2 1 - 1 A ® Piping Sump / Trench Sensor(s) . Model: 3 0 - 3 2 2 1 - 1 ® Piping Sump / Trench Sensor(s). Model: 3 0 - 3 2 2 1 - 1 000010 ❑ Fill Sump Sensogs). Madel: _ ❑ Fill Sump Sensor(s). Model: W Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector, Model: R I - F X - 1 V - D ❑ Electronic Una Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High-Level Sensor. Model: ❑ Tank Overfill / HlgttLevel 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), TankID: Tank Size : Tank ID : Tank Size: L1In-Tank Gauging Probe. Model: ❑ In Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Senors). Model: ❑ Piping Sump / Trench Sensogs). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: 4 � _ ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / Hlgh•Level Sensor. Model: ❑ Tank Overfill / High•Level Sensor. Model: ❑ Other (specify equipment type and model In Section E on Page 2). ❑ Other (specify equlpmant type and model In Section E on Page 2), Dispenser ID: 1 / 2 Dispenser ID: 3 / 4 ® Dispenser Containment Sensor(s). Model: 30 - 3 2 2 1 - 1 ® Dispenser Containment Sensor(s), Model: 3 0 ' 3 2 2 1 - 1 ® Shearvaive(s). ® Shearvelve(s). ❑ Dispenser Containment Float(s) and Chain(e). ❑ Dispenser Containment Float(s) and Chain(s). 01111111111111 Dispenser ID : Dispenser ID: ❑ Dispenser Contalnment Sensor(s). Model: ❑ Dispenser Containment Sensor(s) . Model: ❑ ShearVaNe(s). ❑ ShearVahre(s). ❑ Dispenser Containment Float(s) and Chaln(s). ❑ Dispenser Containment Float(s) and Chaln(s). Dispenser ID : Dispenser ID: ❑ Dispenser Containment Sensogs). Model : ❑ Dispenser Containment Serwgs). Model : ❑ ShearValve(s). ❑ Shearvave(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. Certiflcatlon - I certify that the equlpmmnt identified In this document was Inspectedlserviced in accordance with the manufacturers' guidelines. Attached to this Certdfication is Informatton (e.g. manufacturers' checklists) necessary to verify that this Information is correct and a Plot Plan showing the layout of monftoring equipment. For arty 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): LANE NIMMO / Eric Molgaard Signature: - Certification No. : A28446 jubusluzu License No: 04.1676 7 77�E Testing Company Name: AFFORDA TEST 11jagley n erpnses Phone No. !2091744-0112 Testing Company Address: 416 STREET GALT, CA 96632 / Lodi CA Date of Testing/Servicing: 1 /25/2019 Monitoring System Certification Page 1 of 4 2/21/07