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Appendix VI •California ��'� MONITORING SYSTEM CERTIFICATION h E® Authority Cited: Chapter 6.7, Health and rSafety Code;Use BY All sChapte Withindictions 6Division 3the state f Title 23,California Code4i4 n This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepA{Y�/ ��aN®�� L each monitoring system control panel by the technician whops forms the work.A copy of this form must be provided to the tank sy5tshY 1/p �e / owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of tea A. GeneralInformationformation �4LT bEP� M NAL Facility site S.R.H. -- US GAS Site Addre,a 749 E. CHARTER WAY Bldg.No.: Facility Contact City: STOCKTON — Parcnn Zip: 95205 Make/Model of Monitoring System: VEEDER ROOT TLS-350 Contact Phone No.: ( ) B. Inventory of Equipment Tested/Certified Date of Testing/Servicing; 5/20/2013 Check the a ro nate boxes to indicate specific a ui ment in ected/serviced: Tank ID: 87 Tank Size: ® In-Tank Gauging Probe. Model: MAG 1 Tank ID: Tank Size: ® Annular Space or Vault Sensor. Model: 407 D In-Tank Gauging Probe. Model: ® Piping Sump/Trench Sensor(s). Model: 208 D Annular Space or Vault Sensor, Model: D Fill Sump Sensor(s). Model D Piping Sump/Trench Sensor(,). Model: ® Mechanical Line Leak Detector. Model:* FX-I V D Fill Sump Sensor(,). Model: D Electronic Line Leak Detector. Motlel: D Mechanical Line Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: D Electronic Line Leak Detecto, Model: D Other(specify equipment type and model in Section E on Page 2). D Tank Overfill/High-Level Sensor. Model- Tank ID: DIE Tank Size: El Omer(specify equipment type and motlel in Section E on Page 2). ® Annular Space or Vault Sensor. ® In-Tank Gauging Probe. Tank ID: 91 Tank Size: Motlel: MAG 1 ® In-Tank Gauging Probe. Model: 407 Model: MAG 1 ® Piping Sump/Trench Sensor(s). Model: 208 ® Annular Space or Vault Sensor. Model: 407 D Fill Sump Sensor(s). Model: ® Piping Sump/Trench Sensor(s). Model: 208® Mechanical Line Leak Detector. Model: 99 LD 2000 D Fill Sump Sensor(s). Model: D Electronic Line Leak Detector. Model- ® Mechanical Line Leak Detector. Model: 99 LD 2000 D Tank Overfill/High-Level SensorModel: D Electronic Line Leak Detector. Model. Ci Other(specify equipment type antl motlel in Section E on Page 2). D Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model m Section E on Page 2). Dispenser ID: I/2 ® Dispenser Containment Sensor(,), Model: 208 Dispenser ID: 3/4 ® ShearValve(s). ® Dispenser ConainmentSensor(s). Model: 208 D Dispenser Containment Flcat(s)and Chain(s). ® Shear Valve(s). Dispenser ID: 5/6 ❑ Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Sensor(,). Model: 208 Dispenser ID: 7/8 ® Shear Valve(s), ® Dispenser Containment Sensor(s). Model: 208 D Dispenser Containment Floats)and Chain(s). ® Shear Valve(s). Dispenser ID: ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: D Dispenser Containment Sensor(s). Model ❑Dispenser Containment D Shear Valve(s), Sensor(s). Model: D Dispenser Containment Float(s)and Chain(s). ❑Shear Valve(s). El 'If the acility contains more tanks or dispensers,Copy this form. Include information for every tanlenser Containment oat k and dispenser at the ay. and Chain(,). 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.Far any equipment COPY of the report;(ccapable of generating such reports,1 have also attached a heck he l ar applyam set-up ®Alarm history report Technician Name(print): ZANE NIMMO ®Sys Certification No.: A28448 Signature: Testing Company Name: AFFORDA-TEST License No: 04-1878 Testing Company Address: 4182 STREET GALT,CA 95832 Phone No. 209 744- 0113 DateofTesting/S— ery n 9 5 20/13 Monitoring System Certification Page 1 of 4 2/21/07