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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 NAM, TOYS R US Site Address: 1624 ARMY CT. Facility Contact KEN Person: Bldg. No.: City: STOCKTON Make/Model of Monitoring System: VEEDER ROOT - TLS -300C Contact Phone No.: ( B. Inventory of Equipment Tested/Certified Cherk tha annrnnriata hnYas to indicate snecific enuinment insnected/serviced: zip: 95206 Date of Testing/Servicing: 9/16/2011 Tank ID: Tank Size: Tank ID: Tank Size: N In -Tank Gauging Probe. Model: N In -Tank Gauging Probe. Model. N Annular Space or Vault Sensor. Model: N Annular Space or Vault Sensor. Model: N Piping Sump / Trench Sensor(s). Model: N Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Modem, ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model. ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model. ❑ Tank Overfill I 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: DIE Tank Size: 10 K Tank ID: Tank Size: N In -Tank Gauging Probe. Model: MAG I N In -Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 420 N Annular Space or Vault Sensor. Model: N Piping Sump / Trench Sensor(s). Model: 208 N Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: SUCTION ❑ 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 Dispenser ID: N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s) Model, N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: N Dispenser Containment Sensor(s). Model: N Dispenser Containment Sensor(s). Model: ® Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: N Dispenser Containment N Dispenser Containment Sensor(s). Model: Sensor(s). Model: N Shear Valve(s). ® Shear Valve(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 intormation for every tanK ana dispenser at ine raaory 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): to System set-up ® Alarm history report Technician Name (print): ZANE NIMMO Signature: —W Certification No.: A28446 License No: 041676 `7 Testing Company Name: AFFORDA-TEST Phone No. (209) 7440113 Testing Company Address: 416 2naSTREET GALT, CA 95632 Date of Testing/Servicing: 9/16/11 Monitoring System Certification Pagel of 4 2/21/07