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Appendix VI RECEWED i" MONITORING SYSTEM CERTIFICATION OCT 13 2HEALTH 0�09 l For Use By All Jurisdictions Within the State of California ENV R(N& ENT i 1EALTH Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Californt�11SERUiCES Regulations I' 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 Nl ' TOWS R US Site Adrimms 1624 ARMY COURT Facility Contact Parsnn GLEN Make/Model of Monitoring System: VEEDER ROOT B. Inventory of Equipment Tested/Certified Check tha ann,n infa kn. M i. 4;--t Bldg. No.: City: STOCKTON CA Zip: 95206 Contact Phone No.: (20 9) 465-4912 Date of Testing/Servicing: 9/29/2009 ..._ .__...v "•••-•••- ••,� � .u��... �� w,'�a law a� . PY -10 wiul. P-1— IIIVIIIId I:UII WI evely idnR dnu uispenser aI the racllny. 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: Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 — Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 9-29-2009 Monitoring System Certification Page 1 of 4 2/21/07 M Tank ID: FkDL ing Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: e or Vault Sensor. Model: 420 ❑Annular Space or Vault Sensor. Model: / Trench Sensor(s). Model: 208 ❑ Piping Sump/ Trench Sensor(s). Model: pnsor(s). Model: ❑ Fill Sump Sensor(s). Model: nical Line Leak Detector, Model: SUCTION ❑ Mechanical Line Leak Detector. Model: nic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: verfill / High -Level Sensor. Model: PROBE ❑ Tank Overfill / High -Level Sensor. Model: (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: Tank ID: ❑ 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 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). DispenserlD: DispenserlD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). DispenserlD: DispenserlD: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(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). ..._ .__...v "•••-•••- ••,� � .u��... �� w,'�a law a� . PY -10 wiul. P-1— IIIVIIIId I:UII WI evely idnR dnu uispenser aI the racllny. 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: Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 — Testing Company Address: 416 2" STREET GALT, CA 95632 Date of Testing/Servicing: 9-29-2009 Monitoring System Certification Page 1 of 4 2/21/07