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Appendix VI �W MONITORING SYSTEM CERTIFICATION For Jse By All Jurisdictions Within the State of California 2 Authority Cited: Chapter 6.7, Health and afety Code; Chapter 16, Division 3,Title 23, California Code WR' 20111 Regulations 8dsy Jt This form must be used to document testing and servicing of monitoring equipment.A soP`n thisformmustton or report must be be provided o the tank preparedfor fir'�, T�t each monitoring system control panel by the technician rho performs the work.A copy ownerloperator.The ownerloperator must submit a copy of this form to the local agency regulating t157 systems within 30 days of test date. A. General Information Facility OASIS PLAZA VALERO Bldg.No.: time ' 5240 Site $00 S. CHEROKEE iLN. City: LODI zip: AridrP.,a Facility Contact MIKE Contact Phone No.: Qprcnn' Make/Model of Monitoring System: GILBARCO EMC Date of Testing/Servicing: 2128/2011 _ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspectediserviced: Tank ID: t37 Tank Size: Tank ID: Tank Size: ❑ In-Tank Gauging Probe. Model: MAG 2 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Modet: 420 D Annular Space or Vault Sensor. Model: 208 [1 Piping Sump/Trench Sensor(s). Model: ® Piping Sump 1 Trench Sensor(s). Model [] Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD 2)00 ❑ Mechanical Line Leak Detector. Model: E] Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model: [I Tank Overfill 1 High-Level Sensor. Model: _ El Tank Overfill 1 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: 91 Tank Size: Tank ID: DIE Tank Size: MAG 2 MA 2 ❑ In-Tank Gauging Probe. Model: • In-Tank Gauging Probe. Model: SAME TANK 420 ® Annular Space or Vault Sensor. Madel: • Annular Space or Vault Sensor. Model: 208 20g ® P%ping Sump lTrench Sensor(s). Madel: ® Piping Sump 1 Trench Sensor(s), Model: Model: El Fill Sump Sensor(s). Model E] Fill Sump Sensor(s). 0 Mechanical Line Leak Detector. Model: LD 2000 ® Mechanical Line teak Detector. Model. LD 2000 ❑ Elecironfc tine Leak Detector. Model: ❑ Electronic Line Leak Detector. Model ❑ Tank Overfill 1 High-Level Sensor. Model ❑ Tank OverMI 1 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{D: I/2 Dispenser ID: 314 ❑ Dispenser Containment Sensor(s). Model. ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chains). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser 10: Dispenser 1111 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). l❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s), Model: Sensor(s). Model: ❑ El Shear Valve(s). Shear Valve(s), El Dispenser Containment Float(s)and Chain(s). E3 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 inspectedlserviced In accordance with the manufacturers' guidelines.Attached to this Certification is informat'lon(e.g.manufacturers'checklists)necessary o 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 a1f Mail npply): ❑system set-up ❑Alarm history report not): Signature:ZANE NIMMO Technician Name(p -- License No: 04-1675 Certification No.: A28445 Phone No. (209)744-0113 — — Testing Company Name: AFFORDA-TEST Date of Testing/Servicing: 2/2$�I I Testing Company Address: 416 2 STR€ET GALT,CA 95632 2/21/07 NA—If—i—Svctam Certification -;T Pagel of 4