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0 • k� 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 }ions`" 9,�`D This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be p d �r g each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the t "stem owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 day test da !r,,,,., ,,! 4' m r1f A. General Information 4` # -1014 Facility Name: ERNIE GENERAL STORE Bldg. No.: ENVt TAL HE" Site Address: 4407 WATERLOO RD City: S70CKTON Zip: 71zRVICE$ Facility Contact Person: ERNIE Contact Phone No.: (209) 931-2850 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 01-13-14 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate soecifrc eouinment insnected/sarvirad- TankID: 87 TanklD: 91 ® In -Tank Gauging Probe. Model: MAG 2 ® In -Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump/ Trench Sensor(s). Model: 208 ® Piping Sump/ Trench Sensor(s). Model: 208 D Fill Sump Sensor(s). Model: D Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 2000 D Electronic Line Leak Detector. Model: C Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ® Tank Overfill / High -Level Sensor. Model: FLAPPER D Other (specify equipment type and model in Section E on Page 2). D Other (specify equipment type and model in Section E on Page 2). Tank ID: DIESEL TanklD: ® In -Tank Gauging Probe. Model: MAG 2 C In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor, Model: 407 C Annular Space or Vault Sensor, Model: ZPiping Sump / Trench Sensor(s). Model: 208 D Piping Sump / Trench Sensor(s). Model: D Fill Sump Sensor(s). Model : C Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: PE PETRO D Mechanical Line Leak Detector. Model: Z Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER D Tank Overfill / High -Level Sensor. Model: D Other (specify equipment type and model in Section E on Page 2). C Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 D Dispenser Containment Sensor(s). Model: D 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: 5-6 Dispenser ID: 7-8 D Dispenser Containment Sensor(s). Model: D Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Flcat(s) and Chain(s). DispenserlD: 9-10 Dispenser ID: ❑ Dispenser Containment C 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). 'If the facility contains more tanks or dispensers, wpy 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): ® System set-up ® Alarm history report Technician Name (print): FELIX RAMIREZ Signature: i'C'r f. 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: 01-13-14 _ Monitoring System Certification Page 1 of 4 2/21/07