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• 1AECEIVED Appendix VI MAR 2 7 2017 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of CaliforniaCn1\/IRpNMENTAt HEALTH Authority Cited: Chapter 6.7,Health and Safety Code;Chapter 16, Division 3,Title 23,`Edl, 1rrid RON �TAL H Regulations 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 M.,. GEMCO GAS & GROCERY Bldg.No.: Site 1022 E. FRONTAGE RD. Ci RIPON Zip, Facreaa City: 95366 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 3/6/2017 B. Inventory of Equipment Tested/Certified Check the appropriate,boxes to indicates ecific equipment ins ected/serviced: Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: N In-Tank Gauging Probe. Model: M A G 2 N In-Tank Gauging Probe. Model: M A G 2 N Annular Space or Vault Sensor. Model: 4 2 0 N Annular Space or Vault Sensor, Model: SHARED W/ 87 N Piping Sump/Trench Sensor(s). Model: 2 O 8 N Piping Sump/Trench Sensor(s). Model: 2 0 8 ❑ Fill Sump Sensors). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 99 LD 2000 N Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level 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 an Page 2). Tank ID: Tank Size: Tank ID: Tank Size: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensoir. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensogs). Model: ❑ Piping Sump/Trench Sensor(s). Madel: ❑ Fill Sump Sansone). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overtill/High-Level Sensor. Model: D Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). DlspenserlD: 1 / 2 Dispenser ID: 3 / 4 N Dispenser Containment Sensor(s). Model: 2 0 8 N Dispenser Containment Sensor(s). Model: 2 0 8 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser 10: ❑ Dispenser Containment Sensor(s). Model: ❑ 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: Dispenser ID: ❑Dispenser Containment ❑ Dispenser Containment Sensogs). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑Sheaf 1,ve(s). ❑ Dispenser Containment Float(s)and Chain(s). C:] Dispenser Containment Floats)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,1 have also attached a copy of the report;(check all that apply): N System set-up N Alarm history report Technician Name(print): ZANENIMMO Signature: Certification No.: A26446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2n"STREET GALT,CA 95632 Date of Testing/Servicing: 3/6/2017 Monitoring System Certification Page 1 of 4 2/21/07