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_.iECEIVED Appendix VI NOV 0 7 2016 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California 6I'uWa Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16, Division 3,Title 23,Calif�flJ��IVICN I I�nFsiEALTFi This form must be used to document testing and servicing of monitoring equipment.A separate certification or report mu9[7'�@A�g�7pra ELNT each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to n owner/operator.The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30 days of test date, A. General Information Facility Name: OUICKI KLEEN Bldg.No.. Site Address: 707 E YOSEMITE AVE City: MANTECA Zip: 95336 Facility Contact Person: FRANCENE Contact Phone No.: (209)823-9159 Make/Model of Monitoring System: VEEDER ROOT TIS 350 Date of Testing/Servicing: 10-11-16 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicatespecific equipment ins ectad/serviced: Tank ID: 87 Tank ID: 87 S In-Tank Gauging Probe. Model: MAG 0 S In-Tank Gauging Probe. Madel: MAG 0 S Annular Space or Vault Sensor. Model: 420 N Annular Space or Vault Sensor. Model: 420 S Piping Sump/Trench Sensor(s). Model: 208 S Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: 99 LD 2000 S Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: S Tank Overall/High-Level Sensor. Model: FLAPPER S 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). Tank ID: DIESEL Tari S In-Tank Gauging Probe. Model: MAG 0 ❑ In-Tank Gauging Probe. Model: S Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: S Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: PE PETRO ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: S Tank Overfill/HiglFLevel 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 S Dispenser Containment Sensor(s). Model: 208 S Dispenser Containment Seasons). Model: 208 S Shear VaNe(s). S Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). Dispenser ID: 5.6 Dispenser ID: 7.8 S Dispenser Containment Sensor(s). Model: 208 S Dispenser Containment Sensor(s). Model: 208 S Shear Valve(s). N 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 fora. 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;fcaece all that apo/Y): N System set-up S Alarm history report Technician Name(print): FELIX RAMIREZ Signature: -�t—j Certification No.: 5273934-UT License No: 08-1740 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 _ Testing Company Address: 4162 n'STREET GALT CA 95632 Date of Testing/Servicing: 10-11-16 Monitoring System Certification Page 1 of 4 2/21/07