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Appendix VI MONITORING SYSTEM CERTIFICATION r 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 Ay_ UST systems within 30 days of test date. Tank ID: 91 N In -Tank Gauging Probe, Model: MAG N In -Tank Gauging Probe, Model: MAG N Annular Space or Vault Sensor. Model: 407 N Annular Space or Vault Sensor. i N f Model: 208 N Piping Sump / Trench Sensor(s), Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), v N Mechanical Line Leak Detector. Model: 99 LD 2000 N Mechanical Line Leak Detector. Model: STD MLD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: N Tank Overfill / High -Level Sensor, Model: FLAPPER N Tank Overfill / High -Level Sensor, Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2), EM E tt ryn E�6 e`•I I��rl'.Ift!'i ISE f'fy$ For Use By All Jurisdictions Within the State of California f ; r � � Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Coife 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: MIRACLE MILE MARKET Bldg, No.: Site Address: 244 W HARDING WAY City: STOCKTON Zip: 96204 Facility Contact Person: Make/Model of Monitoring System: VEEDER ROOT Contact Phone No.: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins ected/serviced: Date of Testing/Servicing: 08-22-18 `If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser Tank ID: 87 Tank ID: 91 N In -Tank Gauging Probe, Model: MAG N In -Tank Gauging Probe, Model: MAG N Annular Space or Vault Sensor. Model: 407 N Annular Space or Vault Sensor. Model: 407 N Piping Sump/ Trench Sensor(s), Model: 208 N 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: STD MLD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: N Tank Overfill / High -Level Sensor, Model: FLAPPER N Tank Overfill / High -Level Sensor, Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2), TanklD: TanklD: ❑ 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 3-4 DispenserlD: 1-2 ❑ 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 Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser ContainmentSensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). at the tacwty. 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, 1 have also attached a COPY of the report; (check all that apply): ®System set-up ®Alarm history report Technician Name (pri nt): FELIX RAMIREZ Certification No.: 88830; Testing Company Name: Testing Company Address: Signature: License No: Phone No. Date of Tes Monitoring System Certification Page 1 of 4 2/21/07