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P;• ,J 9+ 2 2��2 • Appendix VI RECEIVED MONITORING SYSTEM CERTIFICATION c D ViEALIR For Use By All Jurisdictions Within the State of California q r 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23,California Code of 990rilalti2r1r012 This form Em be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for GLC each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank systemENW 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 P P eR MEMAL N A. General Information M�/SERVICE$`TM Facility y,,,,e. GEORGE'S MMI MART Bldg.No.: Site Address 18662 N. HWY 88 City: LOCKEFORD Zip: 95237 Facility Contact Persnn Contact Phone No.: ( ) Make/Model of Monitoring System: GILBARCO EMC Date of Testing/Servicing: 5115/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 Tank Size: Tank ID: 89 Tank Size: H In-Tank Gauging Probe. Model: MAG 2 H In-Tank Gauging Probe, Model: MAG 2 ® Annular Space or Vault Sensor. Model: 420 H Annular Space or Vault Sensor. Model: 420 ® Piping Sump/Trench Sensor(s). Model: 205 H Piping Sump I Trench Sensoria). Model: 205 D Fill Sump Sensor(s). Model: D Fill Sump Sensorial. Model: ® Mechanical Line Leak Detector. Model: STP-MLD ® Mechanical Line Leak Detector. Model: STP-MLD D Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: D Tank Overfill/High-Level Sensor. Model: D Tank Overfill I High-Level Sensor. Model: D Other(specify equipment type and model in Section E on Page 2). D Other(specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank Size: Tank to: 91 Tank Size: H In-Tank Gauging Probe. Model: MAG 2 H In-Tank Gauging Probe. Model: MAG I H Annular Space or Vault Sensor. Model: 420 H Annular Space or Vault Sensor. Model: Same as 89 Tank H Piping Sump/Trench Sensor(s). Model: 205 H Piping Sump/Trench Sensoria). Model: 205 D Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 H Mechanical Line Leak Detector. Model: STP-MLD „ D Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model. D Tank Overfill/High-Level Sensor. Model: D Tank Overfill/High-Level Sensor. Model: D Other(specify equipment type and model in Section E on Page 2). D Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 3/4 D Dispenser Containment Sensor(s). Model: D Dispenser Containment Sensor(s). Model: H Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser to: 5/6 Dispenser ID: 7/8 D Dispenser Containment Sensorial. Model: D Dispenser Containment Sensor(s). Model: H Shear Valve(s). H Shear Velvets), ® Dispenser Containment Floats)and Chain(s). H Dispenser Containment Float(s)and Chaints), Dispenser ID: 9/10 Dispenser ID: 9SATELITE & 10 SATELITE D Dispenser Containment Sensor(s). Model: D Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). H 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 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;(dieck all that apply): ®System set-up ®Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676`—' Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 _ Testing Company Address: 416 2no STREET GALT,CA 96632 Date of Testing/Servicing: 5/15/12 Monitoring System Certification Page 1 of 4 2/21/07