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Appendix VI RECEIVED 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 Code 90921 tidW 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 farm must be provided to the tank syste owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test „t,lRONME iAL HEALTH PERMIPSERVICES A. General Information Facility Name. AG SPANOS JET CENTER Bldg.No.: Site Address: 4800 AIRPORT WAY City: STOCKTON Zip: 96206 Facility Contact Person: THOMAS Contact Phone No.: (209)982-1550 MakelModei of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 02-24-17 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate s ecific equipment ins ectedlserviced: Tank ID: JET 1 Tank ID: JET 2 ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 • Annular Space or Vault Sensor. Model: 420 W Annular Space or Vault Sensor. Model: 409 ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump f Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model ❑ Fill Sump Sensor(s). Model: ISI Mechanical Line Leak Detector. Model: FXiVD ® Mechanical Line Leak Detector. Model: FX1VD ❑ Electronic Line Leak Detector. Model ® Electronic Line Leak Detector. Model: ® Tank Overfill I High-Level Sensor, Model: FLAPPER ® Tank Overfill l 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: JET 3 Tank ID: TSA ® In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ED Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Madel: ® Piping Sump!Trench Sensor($). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ t=ill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: LD 3000 HIGH FLOW ❑ Electronic Line Leak Detector. Model: ® Tank Overfill l 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: AV GAS TRANS SUMP Dispenser ID: JET FUEL TRANS SUMP ® Dispenser Containment Sensor(s), Model: 208 ® Dispenser Containment Sensor(s), Model: 208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: FILL FILTER SUMP Dispenser ID: NA 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). Dispenser ID: Dispenser ID: ❑ 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). '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 Inspectediserviced 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 rail that frpplYJ: Cl System set-up ❑Alarm history report Technician Name(print): FELIX RAMIREZ Signature: Certification No,: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 2"d STREET GALT,CA 95632 Date of Testing/Servicing: 2-24-17 Monitoring System Certification Page 1 of 4 2/21/07