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• Appendix VI nn MONITORING SYSTEM CERTIFICATION MAR 3 0 2010 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,CaliforniaWRONMENT HEALTH Regulations PERMUENCES 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 ownerloperstor 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 ame OASIS PLAZA VALERO#1 Bldg.No.: F Site 800 S CHEROKEE LANE CI LODI CA 2i Facility Contact ParanaMIKE Contact Phone No.: (-209)368-1 ' Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 2125/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 OCT Tank ID: 91 OCT ® In-Tank Gauging Probe. Model: MAG 2 ® In-Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: SPLIT W DSL ® Piping Sump/Trench Sensoria). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensoria). Model: ® Mechanical Line Leak Detector. Model: LD-2000 ® Mechanical Line Leak Detector. Model: LD-2000 ❑ 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). Tank ID: DSL Tank ID: S) In-Tank Gauging Probe. Model: MAG 2 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sens8r(s). Model: 208 ❑ Piping Sump/Trench Sensoria). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD-2000 ❑ 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: 1.2 Dispenser ID: ❑ Dispenser Containment Sensoria). Model: YES ❑ Dispenser Containment Sensoria). Model: ® Shear Velvets). ❑ Shear Va(ve(s). Sl Dispenser Containment Floats)and Chalri ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: 3-4 Dispenser ID: ❑ Dispenser Containment Sensoria). Model: YES ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear valve(s). ® Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). DispenserlD: DispenserlD: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Velvets). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)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 tllar 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: 418 2" STREET GALT,CA 95832 Date of Testing/Servicing: 2-25.2010 Monitoring System Certification Page 1 of 4 2/21/07 55�.E►t