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Appendix VI RECEIVE[) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Inn� Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16, Division 3,Title 23,California Code of 1444lalk's?0 1`'{ This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be control panel by the technician who performs the work.A copy of this form must be provided to the tank eye aZ prepared(at,NVIRON each monitoring system coT/t L owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of lest dateHFA`TH D EN I l"�t� EPARTMENT A. General Information Facility Name: RIVER POINT LANDING Bldg.No.: Site Address: 4960 BUCKLEY CLOVE City: STOCKTON Zip: Facility Contact Person: ANDREW Contact Phone No.: (209)961-4144 Make/Model of Monitoring System: RONAN Data of Testing/Servicing: 01-14-14 B. Inventory of Equipment Tested/Certified Check theappropriate boxes to indicate specific equipment ins ectecilserviced: Tank ID: DIESEL Tank ID: 87 OCT ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: LSJ ® Annular Space or Vault Sensor. Madel: LS-3 ® Piping Sump/Trench Sensor(s). Model: LSJ ® Piping Sump/Trench Sensor(s). Model: LS-3 ❑ Fill Sump Sensor(s). 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 f 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 on Page 2). TanklD: TanklD: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Seasons). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). 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 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 Dispenser ID: 3-4 ❑ Dispenser Containment Sansone). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Velvets). ® Sheer Velvets). ® Dispenser Containment Flotilla)and Create). ® Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sarasota). Model: ❑ Shear Valve(s). ❑ Shear Velvets). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensogs). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). 'If the facility contains more tanks or dispensers,copy this form. Ind ude information for every tank and dispenser at the facility. C.Certification-I certify that the equipment identified in this document was inspectedfserviced 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;(,heck all that apply): ❑System set-up ❑Alarm history report Technician Name(print): FELIX RAMIREZ Signature: Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 STREET GALT CA 95632 Date of Testing/Servicing: 01-14-14 Monitoring Systam Certification Page 1 of 4 2)21/07