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RECEIVED Appendix VI AR 2 5 2016 MONITORING SYSTEM CERTIFICATION 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 Codet'MTAL }t1F,%T P9PARTMENT This form must g used W document testing and servicing of monitoring equipment A separate form ub or report to t each monitoring system control panel by the technician who performs the work.A wpy of this form must be provided to the lank system owner/operator.The owner/operator must submit a wpy of this form to the local agency regulating UST systems within 30 days of test date. A. General information Facility Name: QUICK KLEEN Bldg.No.: Site Address: 707 E YOSEMITE AVE City: MANTECA Zip: 95336 Facility Contact Person: FRANCENE Contact Phone No.: (209)823.9169 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 10-21-15 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment Insipectad/serviced: Tank ID: 87 TanklD: 87 ® In-Tank Gauging Probe. Model: MAG 0 ® In-Tank Gauging Probe. Model: MAG 0 ® Annular Space or Vault Sensor. Madel: 420 ® Annular Spew or Vault Sensor. Model: 420 ' ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(a). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensors). 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). ❑ Omer(specify equipment type and model in Section E on Page 2). Tank ID: DIESEL TanklD: ® In-Tank Gauging Probe. Model: MAG 0 ❑ In-Tank Gauging Probe. Model: ® Annular Sparc or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensors). 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: ID 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). Dispenser ID: 1-2 Dispenser ID: 3.4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensors). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7.8 ® Dispenser Containment Sensors). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Velvets). ® 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 Sensors). Model: Sensor(s). Model: ❑ Shear Velvets). ❑Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). 'If the facility contains more tanks ordispensers,wpy this forth. Include information for every tank and dispenser at the facility. C.Certification-1 certify that the equipment Identified In this document was inspectedtserviced 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,1 have also attached a COPY of the report;feheck all that apply): ®System set-up ®Alarm history report Technician Name(print): FELIX RAMIREZ Signature: &--r--- Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date of Testing/Servicing: 10-21-15 Monitoring System Certification Pagel of 4 2/21/07