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Appendix VI • �� MONITORING SYSTEM CERTIFICATION RECEIVED 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 Regulation This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for MAY 3 O each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system 0 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 ENVIRONMENTAL HE4a8 Facility Name: SAVE ON GAS Bldg.No.: PERMIVSEFM&jE Site Address: 420 WEST YOSEMITE City: MANTECA Zip: 95333 Facility Contact Person: SAM Contact Phone No.: (209)267-4400 Make/Model of Monitoring System: Veeder Root TLS 300 Date of Testing/Servicing: 04-29-14 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspectecilserviced: Tank ID: 87 Tank lD: 91 N In-Tank Gauging Probe. Model: MAG 1 N In-Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model: 409 N Annular Space or Vault Sensor. Model: SPLIT W 87 N Piping Sump/Trench Sensar(s). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: PE PETRO N Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: N Tank Overfill/High-Level Sensor. Model: FLAPPER N 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: 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 Sensoria). Model: ❑ Mechanical Line Leak Detector. Model: [I-Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overrill/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: N Shear Valve(s). N Shear Valve(s). N Dispenser Containment Float(s)and Chain(s). N Dispenser Containment Float(s)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 Floats)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 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.Cemfication-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): N System set-up N Alarm history report Technician Name(print): FELIX RAMIREZ Signature: er--- 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: 04-29-14 Monitoring System Certification Page 1 of 4 2/21/07