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DECEIVE® Appendix VI ` FEB 21 2017 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California ENVIR Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Codp E HW -ti This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for A"CES each monitoring system control panel by the technician who perforins 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: ERNIE'S GENERAL STORE Bldg. No.: Site Address: 4407 E. WATERLOO RD. City: STOCKTON Zip: 95215 Facility Contact Person: ERNIE Contact Phone No.: ( ) Make/Model of Monitoring System: GILBARCO EMC Date of Testing/Servicing: 124/2017 B. Inventory of Equipment Tested/Certified Check theappropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tank Size: Tank ID: Tank Size: ® In -Tank Gauging Probe. Model: MAG 2 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 409 ❑ 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: STP - MLD ❑ 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). 11 ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: DIE Tank Size: Tank ID: 91 Tank Size: ® In -Tank Gauging Probe. Model: MAG 2 ® In -Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: SAME AS DIESEL ® Piping Sump / Trench Sensor(s). Model: 2 0 8 ® 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: ❑ 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: 3 / 4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). E9 Shear Velvets). ® Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5 / 6 Dispenser ID. 7 / 8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensors). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Floats) and Cham(s). ® Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9 / 10 Dispenser ID. ❑ Dispenser Containment ❑ Dispenser Containment Sensors). 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, 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): ZANE NIMMO Certification No.: A28446 Testing Company Name: AFFORDA-TEST Testing Company Address: 416 2n0 STREET GALT, CA 95632 Signature:J�--� License No: 04-1676 Phone No. (20 9) 744-0113 Date of Testing/Servicing: 1/24/2017 Monitoring System Certification Page 1 of 4 2/21/07 i� 0231 -7101