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5 Appendix VI MONITORING SYSTEM CERTIFICATION 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 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 Facility Name: PERSHING GAS Bldg. No.: Site Address: 4445 E PERSHING City: STOCKTON CA Zip: 95207 Facility Contact Person: Daljit 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 indicatespecific equipment ins ected/serviced: Tank ID: 87 Tank ID: 91 ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 302 ® Annular Space or Vault Sensor. Model: 302 I@ Piping Sump / Trench Sensor(s). Model: 352 ® Piping Sump / Trench Seasons). Model: 352 ❑ Fill Sump Sensor(s). Model: Cl Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: Cl Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector, Model: PLLD ® Electronic Line Leak Detector. Model: PLLD ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Cl 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 ® Annular Space or Vault Sensor. Model: ® Piping Sump /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: ® Tank Overall / High -Level Sensor. Model: ❑ Other(speciry 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 DispenserlD: 5-6 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: FAILED ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). DispenserlD: 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 Cham(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Velvets), ❑ Shear Valve(s). ❑ Dispenser Containment Floats) 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 info miction 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): astern set-up Cl Alarm history report Technician Name (print): DAVE WNKLER Signature: -�,--� Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0112 Testing Company Address: 416 2nd STREET GALT, CA 95632 Date of Testing/Servicing: 1-30-17 Monitoring System Certification Page 1 of 4 RECEIVED 2/21/07 4PR 10 ZOtr ENVIRONMENTAL HEALTH DEPARTMENT