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A11 Appendix VI 13ECEIVED MONITORING SYSTEM CERTIFICATION For Use By Al Jurisdictions Within the State of California �� Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of RegufaP1Ok7 2016 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must b-ENdNMENTAL each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tan P. n1:104 ,tFk1T' owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days off (lgBgST(�da{{ee�_ A. General Information Facility Name: ERNIE GENERAL STORE Bldg. No.: Site Address: 4407 WATERLOO RD City: STOCKTON Zip: Facility Contact Person: ERNIE Contact Phone No.: (209) 931.2860 Make/Model of Monitoring System: VEEDER ROOT TLS 360 Date of Testing/Servicing: 01-29-16 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauipment inspected/serviced: Tank ID: 87 Tank ID: 91 ® In -Tank Gauging Praha. Model: MAG 2 ® In -Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Ni 407 ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ® Tank Overfill / 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). TanklD: DIESEL Tari ® In -Tank Gauging Probe. Model: MAG 2 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 407 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/ Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: PE PETRO ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ 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). DispenserlD: 1.2 DispenserlD: 3d ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 21 Shear Valve(s). 10 Shear Velvets). ® Dispenser Containment Floats) and Chain(s). S Dispenser Containment Float(s) and Chain(s). DispenserlD: 5.6 Dispenser ID: 7-8 ElDispenser Containment Sensor(s). Model. ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Floats) and Chain(s). DispenserlD: 9-10 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 Chatri '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 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: Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2n" STREET GALT, CA 95632 Date of Testing/Servicing: 01-29-16 Monitoring System Certification Page 1 of 4 2/21/07