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Appendix VI FEB 6 5 2018 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, Californi "M&*TAL HEALTH This form must be used to document testing and servicing of monitoring equipment. A separate certification erred ust a re each monitoring system control panel by the technician who performs the work. A copy of this farm must be provided to the t�a TMENT 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: Site Address: Facility Contact Person: ERNIES GENRAL STORE Bldg. No.: 4407 E WATERLOO RD City: STOCKTON CA Zip: Make/Model of Monitoring System: VEEDER ROOT TLS 360 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Contact Phone No.: Date of Testing/Servicing: 1/22/2018 Tank ID: 87 Tank Size: Tank ID: 91 Tank Size: S In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: MAG 1 S Annular Space or Vault Sensor. Model: 409 N Annular Space or Vault Sensor. Model: 409SPLIT WITH DSL S Piping Sump/ Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: S 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 Overfill / High -Level Sensor. Model: ❑ Tank Ovefill / High -Level Sensor. Model: El 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 Size: Tank ID: Tank Size: S In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: S Annular Space or Vault Sensor. Model: 409 ❑ Annular Space or Vault Sensor. Model: S Piping Sump/Trench Sensoria. Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: S Mechanical Line Leak Detector. Model: 99LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: 1 ❑ 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: 7-8 ❑ Dispenser Containment Sensor(s). Model: FLOATS ❑ Dispenser Containment Sensor(s). Model: FLOATS S ShearValve(s). N Shear Valve(s). S Dispenser Containment Float(s) and Chain(s). S Dispenser Containment Float(s) and Chain(s). Dispenser ID 3-4 DispenserlD: 9-10 ❑ Dispenser Containment Sensor(s). Model: FLOATS ❑ Dispenser Containment Sensor(s). Model: FLOATS S Shear Valve(s). N Shear Valve(s). S Dispenser Containment Float(s) and Chain(s). S Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: FLOATS Sensor(s). Model: FLOATS S Shear Valve(a). ❑ Shear Valve(s). N Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chaints). '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 identifrad in this document was inspeeted/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): S System set-up N Alarm history report Technician Name (print): David Winkler Signature: Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744.0112 Testing Company Address: 416 2n° STREET GALT, CA 95632 Date of Testing/Servicing: 1-22-18 Monitoring System Certification Page 1 of 4 2/21/07