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Appendix VI MONITORING SYSTEM CERTIFICATION MAR I 0 2G1� 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 reg ht6stU9rN2�d-Rir�TAL H EALTH each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the l,� T F NT owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 day''s��oftest 11a��e. A. General Information Facility Name: HARDY'S GAS & FOOD Bldg. No.: Site Address: 16 E. HARDING WAY City: STOCKTON Zip: 95204 Facility Contact Person: HARDEEP Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS -350 Date of Testing/Servicing: 2/21/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 Tank Size: Tank ID: ❑ In -Tank Gauging Probe. Tank Size: Model: ® In -Tank Gauging Probe. Model: MAG I ® Annular Space or Vault Sensor. Model: 4 0 9 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 2 0 8 ❑ Piping Sump /Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 2 0 8 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: RJ -CPT ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: 90% ❑ 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: Tank ID: 91 Tank Size: ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG I ® Annular Space or Vault Sensor. Model: 4 0 9 ® Annular Space or Vault Sensor, Model: SHARED W/ DIE ® Piping Sump / Trench Sensor(s). Model: 2 0 8 ® Piping Sump / Trench Sensor(s). Model: 2 0 8 ® Fill Sump Sensor(s). Model: 2 0 8 ® Fill Sump Sensor(s). Model: 2 0 8 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: RJ -CPT ® Electronic Line Leak Detector. Model: RJ -CPT ® Tank Overfill / High -Level Sensor. Model: 90% ® Tank Overfill / High -Level Sensor. Model: 90% ❑ 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: I / 2 Dispenser ID: 3 / 4 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Dispenser Containment Sensor(s). Model: '_ 0 S ® Shear Valve(s). M Shear Valve(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: 2 0 8 M Dispenser Containment Sensor(s). Model: 2 0 8 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9 / 10 Dispenser ID: ❑ Dispenser Containment ® Dispenser Containment Sensor(s). Model: 2 0 8 Sensor(s). Model: ® 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 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): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 4162 nd STREET GALT, CA 95632 Date of Testing/Servicing: 2/21/2017 Monitoring System Certification Page 1 of 4 2/21/07