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Appendix VI AUG 2 8 2014 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 EW41'RftftWWAL H6ALTo This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be pr lRTMENT 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: Site Address: LOVES TRAVEL PLAZA 1563 COLONY RD City: RIPON Bldg. No.: Facility Contact Person: KEVIN Contact Phone No.: Zip: 95366 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: B-12-14 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tank ID: 87 ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 E Piping Sump/ Trench Sensor(s). Model: 208 E Piping Sump/ Trench Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Fill Sump Sensor(s). Model: 208 ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER E 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: 91 Tank ID: ❑ In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: E Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump /Trench Sensor(s). Model: E Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® 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). Dispenser ID: 1-2 Dispenser ID: 3-4 E Dispenser Containment Sensor(s). Model 208 E Dispenser Containment Sensor(s) Model 208 E ShearValve(s) E ShearValve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ID: 5-6 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 E Dispenser Containment Sensor(s). Model: 208 E ShearValve(s). E ShearValve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 ® Dispenser Containment E Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 E ShearValve(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 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 a// that upp/r): E System set-up E Alarm history report Technician Name (print): FELIX RAMIREZ Signature: 't Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 _ Testing Company Address: 416 2 STREET GALT, CA 95632 Date of Testing/Servicing: 8-12-14 Monitoring System Certification Page 1 of 4 2/21/07