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! Gdv Appendix VI 1 MONITORING SYSTEM CERTIFICATION MAR 6 20^16 For Use By All Jurisdictions Wthin the State of California '—q'i;� �1 VTAL Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16, Division 3,Title 23,California Codel�efFtlf r`q r re.,,_7p^Ta n�r�Ir 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 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: A G SPANOS JET CENTER Bldg.No.: Site Address: 4800 S AIRPORT AVEV City: STOCKTON CA Zip: 95206 Facility Contact Person: THOMAS Contact Phone No.: (209)982-1550 Make/Model of Monitonng System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 2-22-2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins ectedlserviced: TanklD: JET1 WlHigh-Level JET 2 N In-Tank Gauging Probe. Model: MAG 1 k Gauging Probe. iMdel:u 1 N Annular Space or Vault Sensor. Madel: 420 r Space or Vault Sensor. N Piping Sump/Trench Sensor(s). Model: 208 Sump/Trench Sensor(s). ❑ Fill Sump Sensor(s). Model: mp Sensar(s). N Mechanical Line Leak Detector. Model: FXIV D nical Line Leak Detector. D ❑ Electronic Line Leak Detector. Model: nic Line Leak Detector. ❑ Tank Overfill/High-Level Sensor. Model: verfill I High-Level Sensor. ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). TanklD: JETS Tank ID: N In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: N Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensogs). Model: N Mechanical Line Leak Detector. Model: LD 3000 HIGH FLOW ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill I 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: N 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: JET FUEL TRANS SUMP Dispenser ID: N Dispenser Containment Sensor(.). Model: 208 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: FILL FILTER SUMP Dispenser ID: ❑Dispenser Containment N Dispenser Containment Sensor(s). Model: 208 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 orospensers,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): DAVE WINKLER Signature: Certification No.: 5263373-UT License No: OB-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2- STREET GALT CA 95632 Date of Testing/Servicing: 2-22-201fi Monitoring System Certification Page 1 of 4 2/21/07