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Appendix VI RECIFIVED MONITORING SYSTEM CERTIFICATION JUL For Use By All Jurisdictions Within the State of California 2 3 2014 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16,Division 3,Title 23,Californian Code of Regulations This tone must be used to document testing and servicing of monitoring equipment.A separate certification or repo� >��gq(f�r��n L Hen each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to theta 5f8Fh- A HEALTH owner/operator.The owner/operator must Submit a copy of this form to the local agency regulating UST systems within 30 day f4EWPIRTIt IC 4CNT A. General Information w Facility Name: QUICK 8 EASY Bldg.No.: She Address: 824 E YOSEMITE AVE City: MANTECA CA Zip: Facility Contact Person: War Kahn Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 6-30.2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ectad/serviced: Tank ID: 87 Tank ID: 89- 0 In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Specs or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 SPLIT W 91 ® Piping Sump/Trench Sensor(S). Model: 205 ® Piping Sump/Trench Sensogs). Model: 205 ❑ 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: 91 TanklD: ® In-Tank Gauging Probe, Model* MAG 1 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 SPLIT W 89 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 205 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ 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: 3.4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensorts). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 DispenserlD: 7.8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® 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 Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chafti ❑Dispenser Containment Float(s)and Chain(s). .If the facility contains more tanks ordispensere,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'checkliste)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): DAVE VVINKLER Signature: Certification No.: 5273934-UT License No: 078-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)7440113 Testing Company Address: 416 2" STREET GALT,CA 95632 De[e of Testing/Servicing: &30.2014 Monitoring System Certification Page 1 of 4 2/21/07