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Appendix VI fECOVED MONITORING SYSTEM CERTIFICATION JUN U 1 2010 For Use By All Jurisdictions Within the State of CaliforniaNV�PWEIRVICES Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23,CT��ALTRegulations 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 ownerloperator.The owner/operator must submit a copy of this farm to the local agency regulating UST systems within 30 days of test date. A. General Information Facility ra,, . GEORGE'S MINI MART Bldg. No.: Site Adrirwss 18662 N.HVJY 88 City: LOCKEFORD Zip: 95237 Facility Contact Pacenrr. Contact Phone No.: (209)727.3064 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 511112010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspectedlserviced: Tank ID 87 OCT Tank ID: 89 OCT F Z 9 In-Tank Gauging?robe. Model: MAG 2 0 in-Tank Gauging Probe. Model: MAG 2 iZ Annular Space or Vault Sensor Model: 420 ❑ Annular Space or Vault Sensor. Model: 420 ® Piping Sump/Trench Sensor(s). Model: 205 ® Piping Sump l Trench Sensor(s). Model; 205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: 0 Mechanical Line Leak Detector. Model: STP-MLD ® Mechanical Line Leak Detector, Model: STP-MLD ❑ Eleelronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill I High-Level Sensor. Model: ❑ Tank Overfill 1 High-Levet Sensor. Model: ❑ Other(specify equipment type and mode4 in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2) Tank ID: DIESEL 2 Tank ID: 91 OCT _. ® In-'Tank Gauging Probe. Model: MAG 2 ❑ In-Tank Gauging Probe. Model MAG 1 ® Annular Space or Vault Sensor. Model 420 2 Annular Space or Vault Sensor. Model SAME AS 89 21 Piping Sump r 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: 99 LD 2000 ❑ Mechanical Line Leak Detector. Model: STP-MLD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill I High-Level Sensor. Model: ❑ Tank Overfill!High-Level Sensor Model: ❑ Other(specify equipment type and model in Section E on Page 2). E❑ Other(specify equipment type and model in Section F on Page 2). Dispenser ID: 112 Dispenser ID: 314 Dispenser Containment Sensor(s) Model. ❑ Dispenser Containment Sensor(s). Model. ® ShearVallve(s). ® Shear Valve(s), ® Dispenser Containment Float(s)and Chain(s), E Dispenser Containment Float(s)and Chain(s). Dispenser ID: 516 Dispenser ID: 718 © Dispenser Containment Sensor(s). Model: C3Dispenser Containment Sensor(s), Model: ❑ Shear Valve{s) nc Shear Valve(s). ® Dispenser Containment Floats)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). J Dispenser ID: 9110 Dispenser ID: 9 SATELITE& 10 SATELITE Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model, ID Shear Valve(s) ® 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. -T 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 all rhar rrpp&) ®System set-up ®Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-15776 Testing Company Name: _AFFORDA-TEST Phone No. (209)744.0113 Testing Company Address 416-2"STREET GALT,CA 95632 Date of Testing/Servicing: 5111/10 Monitoring System Certification Page 1 of 4 2/21/07 .S.I C 'C+