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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: SHORT STOP 76 Bldg. No. : Site Address: 20 W TURNER RD City: LODI Zip: 95240 Facility Contact Person: ALI Contact Phone No. : (209) 369-3697 Make/Model of Monitoring System : VEEDER ROOT TLS 360 Date of Testing/Servicing : 9-17-18 B . Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced : Tank ID : 87 Tank ID : 91 ® In-Tank Gauging Probe. Model : MAG 1 N In-Tank Gauging Probe. Model : MAG 1 N Annular Space or Vault Sensor. Model : 420 N Annular Space or Vault Sensor. Model : 420 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 : 99 LD 2000 ❑ 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), Tank ID : DIESEL Tank ID : N In-Tank Gauging Probe. Model : MAG 1 ❑ In-Tank Gauging Probe. Model : N Annular Space or Vault Sensor. Model : 420 ❑ Annular Space or Vault Sensor. Model : N Piping Sump / Trench Sensor(s). Model : 208 ❑ Piping Sump / Trench Sensor(s). Model : ❑ Fill Sump Sensor(s). Model : ❑ Fill Sump Sensor(s), Model : N Mechanical Line Leak Detector. Model : FX1V ❑ Mechanical Line Leak Detector. Model : ❑ Electronic Line Leak Detector. Model : ❑ Electronic Line Leak Detector. Model : N Tank Overfill / High-Level Sensor. Model : FLAPPER ❑ 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). DispenserlD : 1 -2 DispenserlD : 34 ❑ 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 : 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 ❑ Dispenser Containment Sensor(s). Model : Sensor(s) . Model : ❑ ShearValve(s). ❑ ShearValve(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) : DAVE WINKLER Signature: ^ l Certification No. : 8883059-UT License No: 08- 1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address : 416 2nd STREET GALT, CA 95632 Date of Testing/Servicing : 9-17-18 Monitoring System Certification Page 1 of 4 2/21 /07