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Appendix A MONITORING SYSTEM CERTIFICATION JUN ] 0 2016 For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Tltle 23,California Code of Regulations This form must be used to document testing and servicing of monitaring equipment.A separate certification or report must be prepared fbrr '' each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system -.. . ..h owner/operator.The owner/operator must submit a copy of this form to the low[agency regulating UST systems within 30 days of test date. A. General Information Facility Name: ALPHA FAST GAS Bldg.No.: Site Address: 2358 E WATERLOO RD City: STOCKTON CA Zip: Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 4-21-2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: TanklD: 87 TanklD: 91 N In-Tank Gauging Probe. Model: MAG 7 N In-Tank Gauging Probe. Model: MAG 7 N Annular Spam or Vault Sensor. Model: 420 N Annular Space or Vault Sensor. Model: 420 N Piping Sump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensods). Model: 205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 99LD 2000 N Mechanical Line Leak Detector. Model: 99LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overall/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). Tank ID: DSL TanklD: NA N In-Tank Gauging Probe. Model: MAG 7 ❑ In-Tank Gauging Probe. Model: N Annular Spam or Vault Sensor. Model: 420 ❑ Annular Spam or Vault Sensor. Madel: N Piping Sump/Trench Sensor(s). Model: 206 ❑ Piping Sump/Trench Sansone). Model: ❑ Fill Sump Sensods). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FE PETRO ❑ 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: 5-6 ❑ Dispenser Containment Sensar(s). Model: ❑ Dispenser Containment Sensor(s). Model: N Shear Valve(s). N Shear Velvets). N Dispenser Containment Float(s)and Chain(s). N Dispenser Containment Floats)and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensods). Model: N Shear Valve(s). N Shear Velvets). N Dispenser Containment Float(s)and Chain(s). N 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 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-1 certify that the equipment identified in this document was inspected/somiced in accordance with the manufacturers' guidelines.Attached to this Certfication is information(e.g.manufacturen'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): ®System set-up N Alarm history report Technician Name(print): DAVE VNNKLER Signature: 44_a _} Certification No.: 5263373-UT Limnse No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2n STREET GALT,CA 95632 Date of Testing/Servicing: 4-21-2016 Monitoring System Certification Pagel of 4 2/21/07