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06 / 28 / 2019 19 : 29 8387674 EMILS PAGE 11 Appendix VI MONITORING SYSTEM CERTIFICATION For Use By Ail Jurisdictions Within the state of California Authority Cited : Chapter 6 , 7r Health and Safety Code ; Chapter 16, Divislon 3 , Title 23 , California Code of Regulations used to document testing end Sung of monitoring equipment. A separate cedi8cation or report must to prepared for This form must be each monitoring system u5jea control panel by the technician who porformB the wont. A copy of this form must be provided to the tank system ovwnerloporator. The ownerloperator must submit a Copy of this form to the incel agency regulating UST systems w thin 30 days of test date. �. General Infotmauon Biag. No. : FacilityKIEMIL' S LI UOR & SPORTS SHOP Zip: 95320_ Ncny: ESCALON She 1405 CALIFORNIA ST . address• Contact Phone No. : (209) $38 -7674 Facility Contact CHACKO Persom •VEEDER ROOT TLS 350 DatcofTeOlinglServicinp: 912712019 MakelModel or Monitoring System: B, Inventory of Equipment Tested/Certifled Chock the a ro ariato boxes to Indicate s ecifie a ui ment ins clodfgervtced : 9 Tank ID: Tank Sino: Tank ID: 87 Tank size: MAG-2 ® In Tank Gauging Probe. Model: 0 In-Tank Gauging Proms. Model: MAG-2 Model: 4.20 420 ® Annular Space or Vault Sensor. ® Annular Space or Vault Sensor. Model: �—� 208 Model: 20S ® piping sump / Trench Sensor(s) , Model^., 0 Piping Sump I Trench Senaor(s) Model: Model. ❑ pili Sump Sensor(s). F�{IV ❑ Fill sump seneor(s). 1 D 2000 Model:� Mechanical Line Leak Detector. M —.�--- ® Mechanical Line Leak Detector. Model: [D Eledronle Line Leak Deledof. Model: C] Electronic Line bask Deledor. Model: d Tank overfill I Hig4-Level Sansor. Model' ❑ Tank Overfill I HigtrLcvel Sensor. Model ❑ Other (specify equipment type and model in Section E on Page 2). El other (spec6Y equipment type and model in section E on Page 2), Tank Size: Tank Size- Tank ID: Tank ID. DIEModel ® In-Tank Gauging Probe. Model: Nv[A-G -2 Q In-Tank Gauging Probe. 420 ❑ annular Space or Vaud Sensor Model: 0 Annular Space orvauh Sensor. Model: ❑ Piping Sump / Trench Seneo((s). Model: ® Piping Sump 1Trench Seneons)• Model: 20 $ Model: Modem. 0pill Sump Sensor(s), C] Fiji Sump Sensor(e), C Model: Modelo } XIV Cl Mechanical line Leak petector W Mechanical Line Leak Detector. M ❑ Erectronle Line Leak Dstedor. Model C) Electronic Line leak Detector. Model ❑ Tank Overfill / Nigh-Level Senso(. Model: D Tank Overfill I High-Level Sensor, Model : C) Other (specify equipment type and model in Section E on Page 2), 0 Other (specify equipment type and model In Section E on Page 2), Dispenser ID: 3 - 4 Dispenser ID ; I '2III IIII IIII Ilion Q Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment 6ensor(a). Model: � ShearValve(s), r� Shear valve(s). 0 Dispenser Containment Float(s) and Chein(e). ® Dispenser Cordainment FioAI and Chain(*) , Dispenser ID: WIN MIMI DiapanserlD: pi nserContalnmemSensor(s). Model: ❑ Dispenser Commitment Sensor(a). Model: ❑ Shear Vraive(s)., ❑ Shear V21ve(s). Q pspenser Containment Fiosl(S) and Chatn(s), Q DWpenser Containment Ftort(s) and Chain(S). DlspaiI ID: Dispenear ID: ❑ Dispenser Containment I . ❑ Dispenser Cordainmer4 Sensor(s). Model : Sensor(s) . Model : ❑ Shearvalve(s) . E] Shesr Valve(s). [I Dispenser Containment; Float(s) and Chain(s) . C] PiapenSer Contoinment F1061(s) and Chain(e}. •If the (I contains more tanks or dispensers, copy this form. Indata information for every lank and dispenser at the (stilly, Wit C. Certification - 1 certify that the equipment identirfied in this document wile impeatcd/serviced in accordance ry to verify that the manufacturers" Is correct guidelines . Attached to this certificadon is Infonnatiu pm nt For any equipment capable of genera tJn9 sh reports , I have aaieotatteche9a and a Plot Pian showing the tayotrtef monitoring system Set-up ® Alarm nistory report copy of the report; (check all (flat apply): IIIh Signature: — Techntdan Nelme (Primal) : r�D SYEARNS License No: �� Certification No.: A31048 Phone No, 209 7440113 Testing Company Neme; AFPORDA-TEST Date of TestiaglServidng: 6/27/ 18 — Teating Company Address: 416 2"° STREET GALT, CA 95832 2;2 ) /07 page 1 of 4 Monitoring syetem Certification I Received Time Jun , 28 , 2019 7 : 27PM No , 5223 I •