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• t r t � Appendix VI MONITORING SYSTEM CERTIFICATION JUN 02 2011 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 Codi,fj0AQU.%j COUNTY Regulations ENVIt CNIlr,E°JTAL HE?LTH CIEPARTMENT 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 GEORGES MINI MART CHEVRON Names• Bldg.Ne.: Site Address: 18662 N HWY 88 City: LOCKFORD CA Zip: 95237 Facility Contact Person: RUPI Contact Phone No.: ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 511 912 01 1 B. Inventory of Equipment Tested/Certified Check theappropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tank ID: 91 Z In-Tank Gauging Probe. Model: MAG 2 ® In-Tank Gauging Probe. Model: MAG 1 lH Annular Space or Vault Sensor. Model 420 ❑ Annular Space or Vault Sensor. Model: SPLIT ® Piping Sump I Trench Sensor(s). Model: 205 ® Piping Sump/Trench Sensor(s). Model: 205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: STP MLD ® Mechanical Line Leak Detector. Model: STP MLD ❑ 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). Tank ID: DSL Tank ID: 89 ® In-Tank Gauging Probe. Model: MAG 2 ® In-Tank Gauging Probe. Model: MAG 2 I8 Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model 420 0 Piping Sump/Trench Sensor(s). Model: 205 ® Piping Sump I Trench Sensor(s). Model 205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model LD 2000 ❑ Mechanical Line Leak Detector. Model: STP MLD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill I High-Levee 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 Dispenserii 5-6 d Dispenser Containment Sensogs). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Floats)and Chain(s). ® Dispenser Containment Float(s)and Chairi Dispenser ID: 3-4 Dispenser ID: 7-8 ❑ Dispenser Containment Sensogs). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). Z Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9-10 Dispenser ID: 9 SAT AND 10 SAT ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model! Sensor(s). Model; ® Shear Valve(s). Z Shear Valve(s). ® Dispenser Containment Floats)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 inspectedlserviced 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 alllhal apply): ❑System set-up ❑Alarm history report Technician Name(print): DAVE WINKLER Signature: _ I Certification No.: 5283373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 STREET GALT,CA 95632 Date of Testing/Servicing: 5-19-2011 Monitoring System Certification Page 1 of 4 2/21/07