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• • RECEIVE Appendix VI MONITORING SYSTEM CERTIFICATION MAY 21 2015 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 E"RIMMENTAL This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be pr f9 W PI=A CITBACKIT each monitoring system control panel by the technician who performs 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. Geneml Information Facility Name: SAVE ON GAS Bldg.No.: Site Address: 420 WEST YOSEMITE City: MANTECA Zip: 95333 Facility Contact Person: Contact Phone No.: (209)267-4400 Make/Model of Monitoring System: VEEDER ROOT 300 C Date of Testing/Servicing: 4-17-15 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicatespecific equipment ins ectedlserviced: TanklD: 87 TanklD: 91 ® In-Tank Gauging Probe. Model: MAG 0 ® In-Tank Gauging Probe. Model: MAG 0 ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Model: SPLIT W 87 ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensors). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leek Detector. Model: PE PETRO ® Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill/High-Level Sensor. Model: FLAPPER ® Tank Overall/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: TanklD: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Madel: ❑ 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 DispenserlD: 3-4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® ShearValve(s). ® Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Floats)and Chain(s). Dispenser ID Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ 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 Dispenser ID: ❑Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Velvets). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chairl '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 inspectediserviced 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 21 Alarm history report Technician Name(print): DAVE WINKLER Signature: r1 � Certification No.: 5273934-UT License No: 0488--`17'4'10 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 STREET GALT,CA 95632 Date of Testing/Servicing: -4-17-15 Monitoring System Certification Page 1 of 4 2/21/07