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R E E V �:Appendix V! .� ,®, MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California2 2;18 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of d�egulations 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 farm must be pl��AL��1 owner/operator. The ownerloperator must submit a copy of this form to the local agency regulating Ut isr ST system A. General Information DEPARTMENT Facility Name: Site Address: PERSHING GAS Bldg. No.: 4445 E PERSHING City: STOCK ON CA Zip: 96207 Facility Contact Person: NANCY Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT SIMPLICITY Date of Testing/Servicing: 1-30.2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific enuinment inSnertPdlcervirrLH- Tank ID: 87 Tank ID: 91 ® In -Tank Gauging Probe Model: MAG 1 Z In -Tank Gauging Probe. Model MAG 1 ❑ Annular Space or Vault Sensor. Model: 302 Z Annular Space or Vault Sensor, Model: 302 ® Piping Sump / Trench Sensor(s). Model: 352 ® Piping Sump / Trench Sensogs). Model: 35.2 ❑ 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: PLLD ® Electronic Lane Leak Detector, Model: PLLD ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipmenttype 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: ® In -Tank Gauging Probe. Model MAG 1 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 302 0 Annular Space or Vault Sensor. Model: ® Piping Sump 1 Trench Sensor(s). Model: 352 ❑ 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: PLLD ❑ Electronic Line Leak Detector. Model ❑ Tank Overfill / High -Level Sensor. Model: 12 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: 5-6 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: FAILED ® ShearValve(s). ShearValve(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser ContainmentSensor(s). 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. 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; (check all that apply): Z System set-up ® Alarm history report Technician Name (print): DAVE WINKLER Signature: � '6. _ ) Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0112 Testing Company Address: 416 2"d STREET GALT CA 95632 Date of Testing/Servicing: 1-30-17 Monitoring System Certification Page 1 of 4 2/21/07