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Appendix VI RFGF-i.14"xED FEB 1 5 MONITORING SYSTEM CERTIFICATION 2D18 For Use By All Jurisdictions Within the State of California Authority Cited. Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of -V EN T hL iF:,'%LTH Regulations T 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 form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility PERSHING BEACON ti�..+a� Bldg. No.: Site Address- 4445 NORTH PERSHING City: STOCKTON Zip: 96207 Facility Contact Person, DALJIT _ Contact Phone No.: (209) 298-3183 MakelModel of Monitoring System: VEEDER ROOT SIMPLICITY Date of Testing/Servicing: 113112018 B. Inventory of Equipment Tested/Cerlified Check the annrnni. hnyaa to inrtipato enariiir arrninmant G..o.,nrto�ll��.,.ir�a Tank ID: 87 Tank 1D: 91 M in -Tank Gauging Probe. Model MAG 1 M In -Tank Gauging Probe. Model: MAG 1 El Annular Space or Vault Sensor. Modef: 302 M Annular Space or Vault Sensor. Model: 302 M Piping Sump I Trench Sensor(s). Model: 352 ® Piping Sump I Trench Sensor(s). Model: 352 ❑ 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: PLLD ® Tank Overfill / High -Level Sensor. Model: FLAPPER M Tank Overfill I High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2) ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank ID: M In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 302 ❑ Annular Space or Vault Sensor. Model: M Piping Sump I 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 1 High -Level Sensor. Model: FLAPPER ❑ Tank Overfill I High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section F on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ❑ Dispenser Containment Sensogs). Model: ❑ Dispenser Containment Sensor(s). Model: M ShearValve(s). M ShearValve(s). M Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Ficat(s) and Chain(s). Dispenser ID: 6-6 Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s), Model: M ShearValve(s). ❑ ShearValve(s). M Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s),. Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(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). .. - .- .__...., ., ,.. ,.,.,i-," --?'r .�,3,.,, — ,, ,Vi orcIY -I IN -4V QIapvnxi at LI IU idcwry. 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): FELIXRAMIREZ Signature: FELIX RAMIREZ Certification No.: 834976 License No: 5273934 -UT 08-1740 OTTL Testing Company Name: AFFORDA-TEST Phone No. 206 744-0113 Testing Company Address: 416 21 STREET GALT, CA 95632 Date of Testing/Servicing: 01-31-18 Monitoring System Certification Page 1 of 4 2/21/07